Dibattito precongressuale
2° CONGRESSO S.E.P.I. ITALIA Firenze 24-26 Marzo 2006
Pagina 3
Hilde Rapp, 27 Febbraio 2006
Alan wrote :
<<As Tullio argues, what calls for integration in psychotherapy are the various strategies and techniques of intervention/healing—a pragmatic integration>>.
I agree. For me the question here becomes: what outcome do we seek to achieve? For the sake of argument, the psychoanalyst might say that the aim of the therapy- the outcome it drives towards, is that the client should complete the developmental task of emotionally separating from his/her mother in order to become a viable adult. The cognitive behaviour therapist might reformulate this as the client needs to learn certain cognitive behavioural skills which involve the false belief that they cannot function without their mother, the emotional skill of managing their own emotions, social skill of learning to ring up friends when miserable, practice managing their anxieties when decision making etc etc…The analyst might agree that this is the way forward, but might choose to express the means in theoretically driven different language… and this story could be told with respect to most approaches current in psychotherapy…
Past Sepi conferences have demonstrated how good our colleagues are in this sort of exercise in translation, transposition and reformulation.
Alan went on to say:
<<The theories, in contrast, because they are not only incomplete but also false, call not for integration but replacement via rethinking and reconceptualization. The theory of evolution does not represent any kind of “integration” of the previously existing theory of divine creation>>
If we go back to the original meaning of “theory” (theorein) in Greek, it means “a way of seeing” , rather than a an body of laws or relationships which organize a set of systematic observations. It seems to me that most of our psychotherapeutic ” theories” function more like values which organize our preferred ways of seeing- or understanding the observations, presumed facts, and our relationship to what we know and do in the complex world around us. The African philosopher John Mbiti once observed that theories are stories that help us to cope with our fear of the unknown…
I therefore agree that we are working in a proto- theoretical space, and I submit that the value of the kind of meta-theoretical framework I am proposing is that it can act as a shared ground map which allows us to organize such ‘stories’ in terms of the underlying values and facts that particular individuals and professional ‘schools’ see as particularly helpful for our practice.
Working integrat- ively then becomes not the endeavour to seek a synthesis or resolution of differences, but rather, an effort after seeking an understanding of how different positions are articulated, what conflicts arise between them and when, where , why and in what context this matters.
As Andre pointed out, this is also the arena where Spiral Dynamics and Integral Theory are making a contribution, not necessarily specifically to psychotherapy, but to our general understanding of the dynamic evolution and articulation of value systems with proto-theoretical content and how to work with conflicts between them.
After such a ‘diagnosis’ of the actors and positions in a given conflict, such a meta-framework also allows us to collect and organize best practice examples of how to transform these conflicts in a particular practical situation where colleagues are at loggerheads about the ‘treatment’ of a particular client or patient.
The journal of Psychotherapy Integration is full of such best praxis examples- and George has contributed many – and indeed our SEPI conferences are always an exercise in conflict transformation in action. Of course there are entrenched conflicts for which we have not found a process, or perhaps we haven’t tried yet…
Allan Zuckoff, 27 Febbraio 2006
George wrote:
<<My preference is for an assimilative approach to integration, in which a preferred theory is maintained and techniques from other approaches are assimilated. However, the challenge after successful assimilation is accommodation - changing the home theory so that it can accommodate a technique that originally would not have been suggested by it. Is accommodation possible or must the theory be discarded in favor of a synthesis? I don't know, and that is the challenge we face>>.
I think this model, drawn as it is from Piaget’s model of individual learning, provides an appealing account of the process of the (ideal) individual practitioner. For anyone who is plying his/her trade as a psychotherapist, challenges will arise that cannot be neatly fit into one’s existing sense-making structure; whereas the rigid therapist rejects the apparent anomaly and insists upon forcing the new challenge into his/her procrustean theoretical bed, the open therapist acknowledges the poorness of fit and adapts to the novel circumstance.
But, how much do practitioners’ “theories” change, as opposed to their praxes? If I am a client-centered therapist and I notice that whatever client speech I empathize with occurs more frequently, how likely is it that I will conclude that my empathy is merely (and mechanically) reinforcing the client for certain verbal behaviors? I think it’s more likely that I will conclude that I am empathizing accurately, inviting the client to explore more thoroughly that area of his/her experience, and perhaps incorporate the idea that I can guide my sessions towards deeper exploration by empathizing more actively. Because client-centered and behaviorist theories offer not just different, but mutually exclusive accounts of why people act the way they do—and once I buy into the theory of reinforcement, I’m forced to admit that I’m not eliminating conditions of worth but merely changing them into more benign versions.
Thus I’m not sure the assimilative model does the job from the standpoint of the theoretical development of the discipline. This is essentially a model of “normal science” in Kuhn’s sense: when a widely-accepted theory provides the foundation for a great deal of new knowledge discovery, it is maintained via small accommodations. But if our field is still pre-paradigmatic—driven by incompossible theories—then I think what is needed may be more “philosophizing with a hammer.”
Allan Zuckoff, 27 Febbraio 2006
Dear Hilde,
I find much of what you propose helpful to my own thinking about these matters.
The statement that <<most of our psychotherapeutic ” theories” function more like values which organize our preferred ways of seeing- or understanding the observations, presumed facts, and our relationship to what we know and do in the complex world around us>> captures something important for me, going directly to my sense of a disconnect between what we normally mean by the term “theory” and the way that “theories” seem to function in the work of practitioners.
Yet I also wonder whether the theories themselves—psychoanalysis versus behaviorism, say—are so readily integrated as your example suggests. The behaviorist may admit that the source of a dysfunction lies in the early history of an individual—presumably the occasion of the “false belief that they cannot function without their mother”—but will also insist that the belief was established via reinforcement patterns that have presumably continued to obtain. The psychoanalytic claim that, say, the “belief” is grounded in fixation of cathexes will presumably be given short shrift. So I believe that what you have successfully re-languaged remains at the level of praxis, rather than of theory.
I also remain uncertain about the value of “meta-theory” in the sense you are describing. In the beginning of The Order of Things, Foucault quotes a story by Borges, in which a certain ancient taxonomy goes something like this (I paraphrase broadly, and with apologies): a) Solid things b) heavy things c) things that belong to the emperor d) things that from a distance look like a chicken…
Foucault’s point, of course, was that the conceptual space within which such a taxonomy could be comprehended no longer exists, and is so foreign to our own as to render those letter labels [a), b), c)] absurd to us. However, unlike Foucault, I would want to argue that this taxonomy is not merely the product of a different “episteme,” but an inferior one. Because if knowledge does not progress, but merely changes, then we are all absurd.
My concern about the “metatheoretical space” defined by Andre is that it is uncomfortably like Borges’ taxonomy, and I’m not sure what is gained by placing conflicting constructs in a defined order, or within a single plane. While I see the value in trying to draw out commonalities among competing theories, once again at the level of praxis, I don’t think we will achieve maturity as a discipline until we are precisely able to achieve, at the level of theory, “a synthesis or resolution of differences.”
David Allen, 27 Febbraio 2006
I completely disagree that there is no common grounds on which the theories of psychoanalysis, psychopharmacology, behavior therapy, cognitive therapy, humanistic therapy and family systems theories can meet. In my opinion, it only appears that way if one views these theories as monolithic wholes that must be accepted or rejected in their entirety, and conceptualize the various theories based on the arguments of each theory's most extreme, reductionistic adherents. Each theory is in fact a collections of ideas with common threads that are then applied to various observed phenomena in an attempt to understand them. Some of the conclusions based on theory may be right while others completely wrong.
No behaviorist I know thinks that human behavior is ONLY determined by external contingencies. They just choose to intervene there. Social learning theorists even look at the interpersonal environment, although they do so in an un system-atic way (if you'll pardon the pun). Likewise, you don't have to believe that OCD is caused by harsh toilet training (an empirically disproved idea from analytic theory) to believe in the general validity of the concept of defense mechanisms (even if you call them mental schemas or automatic thoughts).
Tullio, you could in fact approach what happened with your obsessive patient using a theoretical integration of pharmacology and psychotherapy, such as a stress-diathesis model.
Hilde Rapp, 27 Febbraio 2006
Dear Allan,
Thank you. I agree with most of what you say, which suggests to me that I have – as I do from time to time- left out parts of the argument because they are too familiar to me by now.
Yes, I agree that the potential accommodation between the caricatured analyst and behaviour therapist positions is entirely pragmatic- they would agree on what needed to be done, but they would go about it by different methods/techniques and they would justify what they do differently- ie take recourse to different as well as- usually- incompatible theories. The proposed common ground is purely functional.
In a previous mail to Andre I voiced similar concerns to those advanced by you, although less eloquently and explicitly. Tongue in cheek: fuzzy semantics are useful to a degree, but beyond that they become woolly ! Even in a scenario where we could ever work in an “integral” manner, sufficiency would increasingly work against transparency and one would need an international mainframe collaboration to work out a therapeutic algorithm! In any case, temperamentally, I would probably always have an aversion to any approach that is potentially totalizing- Bob Niemeyer made a very good case about this some years ago, reminding us of an attempt by Goebbels’ cousin to create an integrat-ed psychotherapy in Nazi Germany…
So, my integrative framework should perhaps be simply called a meta-framework rather than a meta-theoretical framework? It transcends theories in so far as it does not aim to integrate them but merely to organize them. Its purpose is to give us a shared ground map which allows us to map or locate theories with respect to their central focus: does the theory focus most strongly on subjective experience (Q1) , does it focus on culturally situated inter-subjective dialogue (Q2), does it aim to organize on neuroscientific and cognitive-emotional- developmental research findings into new understandings of the human mind/psyche? (Q3), or does it focus on the socio-economic, environmental and political determinants of mental ill health (Q4) or, to be more specific, does it look at sociological factors from a hermeneutic position (say Foucault, then it would be Q2 &Q4) or more from a positivist position (empirically grounded, drawing more on quantitative studies, say evolutionary theory) then it would be located across Q3&Q4…
The purpose of such a mapping would be to explore along which axes of enquiry the major conflicts lie with a view to learning something from each other without giving up our positions if the approaches look like they are too incompatible. This would be to advance academic enquiry and practical skill and knowledge building and CP/E/D.
Or more practically still, we might want/ need to transform a conflict between colleagues with shared responsibility for a shared patient or client- Tyler’s issue, for example – this would be leadership and conflict transformation work.
What we tend to learn by using a meta framework approach and we can tolerate, nay, embrace difference and healthy competition, is usually a new technique which borrow and assimilatively integrate into our own approach.
What we are invited to let go off is our fear of difference, our competitive desire to win, and our discomfort in the face of not knowing and our anxieties about not being in control…
Tullio Carere, 28 Febbraio 2006
Paolo Migone wrote:
<< Dear Tullio, I have the feeling that to rely on ethics is quite useless, especially today when we are in a multi-cultural, multi-ethnic and pluri-religious age. Everybody knows that a given cultural population may have ethical principles that are considered unethical by others. And everybody knows, as well, that often the therapists who do big technical "errors" o behave unethically (according to other therapists) say that they did the right thing and/or "rationalize" their behaviour.
I think we need to find other ways to deal with the problems you are discussing about >>.
Dear Paolo,
Do you really believe that we can leave ethics out of the door? Ethics is the study of how we decide that a choice is good or bad, right or wrong. Psychotherapy is ethics, from start to end. In an era dominated by the myth of science many people believe that science is neutral, i.e. not grounded on ethical and metaphysical choices. Modern epistemology has dismantled this myth (even Popper had to grudgingly admit it, in the end). For instance, the evidence based psychotherapy is based on the belief that you can extract a procedure from the relationship in which it is embedded, and administer it to a patient in the same way as you administer a drug. You choose to believe that psychotherapy works like medicine, and you produce empirical data to support your belief. You can produce empirical data to support almost any belief (even the belief in miracles: at the Vatican they have a scientific faculty for that).
In ethics you have three levels. At the ground level (preconventional) you are the lawmaker: you decide what is right or wrong, you don't care what other people think. At the second floor (conventional) you submit to some conventional law: you are the follower of some school or theory, you behave according to the principles of your convention - for instance, you administer protocol driven procedures. At the third floor you suspend as much as you can all your presuppositions and expectations; you try to understand what every individual situation requires, and behave accordingly; in the awareness that your perceptions and evaluations are limited and fallible, you constantly look for feed-back, dialogue and confrontation. All three levels are present in different proportions in most of us. Genuine dialogue happens at the third floor. Faith in dialogue (dia-logos) is the belief that you can move in life (and in therapy) beyond all conventions, guided by the inherent logic of any process (the logos) that manifests itself in the relationship between (dia) people willing to let go of any preconceptions and expectations to open up to it.
Hilde Rapp, 28 Febbraio 2006
Dear Tullio, dear Paulo,
In haste: perhaps it would help to distinguish between ethics and morality on the one hand and religion and spirituality on the other.
Crudely, by rule of thumb: ethics relates to principles of natural or distributive justice, while morality relates to conforming to the rules and codes of conduct that are the norm ( conventional) in a given cultural reference group.
In a similar vein, spirituality relates to principles that help us to establish a relationship to the Sacred ( Divine to some) as such and in ourselves and in our fellow living beings ( by whatever name or none), while religion ties us into sets of beliefs and rituals which constitute a particular theology and faith based practice…
While morality is grounded in ethics and religion is rooted in spirituality, a person can act ethically and yet contravene prevailing moral dictates ( a white person having relations with a black person in Apartheid South Africa, which would have been illegal to boot!), just as a spiritual person may be burnt at the stake for heresy…
Having said that I agree with you Tullio, that psychotherapy is a profoundly ethical practice, and- if I read you correctly- I agree with you Paulo, that morality has no place in it- other than as information about what the client believes or what she might be up against!
Allan Zuckoff, 28 Febbraio 2006
Dear Hilde,
Thank you for taking the time to lay out your argument more explicitly; it seemed very clear, even in pre-edited form. I do think that we agree on many things, although I’m not at all daunted by the prospect of a “totalizing” theory of psychotherapy—in fact, I think that should be our goal (just as a “unified theory” is the goal of physics), but I’m certain that the approach to such a theory (for such finite creatures as ourselves) will be asymptotic.
Your “meta-framework” sounds like it is organized to lead to the overcoming of conflicts among theories via higher-order syntheses, though without demanding that adherents give up their individual theories until they are ready to do so. More than anything, this seems like a skillful therapeutic intervention for academics: invite them to relax their defenses enough to consider other perspectives, but avoid generating resistance by not trying to strip those defenses away?
Allan Zuckoff, 28 Febbraio 2006
David,
I certainly agree that, in practice, adherents of competing theoretical schools borrow from other schools and reject aspects of their own. But I disagree with your definition of theories as “collections of ideas with common threads that are then applied to various observed phenomena in an attempt to understand them.” I understand theories as well-organized explanatory frameworks, which can be applied to a range of phenomena and which are capable of generating either hypotheses that can be tested empirically or truth-claims that can be evaluated rationally. While certain peripheral aspects of a given theory (e.g., accounting for OCD via anal eroticism) can be rejected without having to abandon the theory altogether, challenges to the theory’s fundamental assumptions (e.g., psychosexual development or unconscious process) can render them useless.
You may well be right that there are no behaviorists left who believe that behavior is determined only by external contingencies; I hope that’s true. But the very construct of “external contingencies”is not theory-neutral; rather, the claim that human beings react in lawful ways to “stimuli” (another theory-specific construct: there is purported to be a meaningless physical environment “outside” the person) is, for example, rejected by phenomenological and Gestalt theories of what is, and where human beings fit in what is. At this level, both theories cannot be correct—and the implications of which is true (or, at least, truer) are profound with regard to how we view the people we seek to help.
Stephan Tobin, 28 Febbraio 2006
Allan,
That idea of an external reality from which the individual is separate and "stimulated by" is a good example of the individualist paradigm, i.e., that the self exists prior to interaction with the environment, rather than seeing the person/environment as part of a phenomenological, intersubjective field. I'm pleased that you mention Gestalt here. Even though Perls was a prime example of the individualist paradigm in his behavior, the Gestalt theory has always stressed a more intersubjective paradigm.
David Allen, 28 Febbraio 2006
Psychosexual development and unconscious processes are examples of what I was trying to talk about - they seem to me to be very different ideas tied together with some common assumptions. Even within a given construct, however, is it not possible that the various analytic ideas about, say, psychosexual development are partly correct and partly wrong? The different subschools of psychoanalysis can't even agree among themselves about all the particulars - Kohut had to invent a whole new psychic agency (the self) just to get his ideas across in order to remain "in the club." I believe even fundamental assumptions within a theoretical construct can be modified with new evidence without having to throw the baby out with the bathwater.
I agree that the construct of "external contingencies " is not theory neutral - strict constructivists don't even believe that such an external reality exists. If one believes that solipsism is the totality of the universe, I guess they could never even talk about external conditions. But that is the type of radical, reductionistic type of stance that is more like religion than science. Perls wasn't like that - he wrote extensively about disturbances at the interface between individuals and their social world. The word interface inherently refers to two of something.
Allan Zuckoff, 28 Febbraio 2006
Stephan Tobin wrote:
<<Even though Perls was a prime example of the individualist paradigm in his behavior, the Gestalt theory has always stressed a more intersubjective paradigm>>.
David Allen wrote:<< Perls wasn't like that - he wrote extensively about disturbances at the interface between individuals and their social world>>.
American though I am, my training in philosophy was Continental; when I use the term Gestalt, I intended to refer not to the “gestalt therapy” of Perls, but to the Gestalt psychology of Lewin, Kohler, und so weiter… Thus we all agree (I think): there is fundamental disjunction between atomistic and holistic models. And perhaps that disjunction is consequential?
David wrote: <<Psychosexual development and unconscious processes are examples of what I was trying to talk about - they seem to me to be very different ideas tied together with some common assumptions. Even within a given construct, however, is it not possible that the various analytic ideas about, say, psychosexual development are partly correct and partly wrong?... I believe even fundamental assumptions within a theoretical construct can be modified with new evidence without having to throw the baby out with the bathwater>>.
Your point is well-taken: it is clearly possible to jettison the sub-theory of psychosexual developmental stages and still maintain the validity of the construct of, say, the active unconscious. Although then, one is no longer a Freudian analyst, but perhaps a psychodynamic psychotherapist. But what happens if one jettisons the construct of the active unconscious? Can one still claim to hold the theory of psychoanalysis as valid? It’s hard for me to imagine what would be left—and I suspect at that point one would have to say that the theory of psychoanalysis no longer offers enough explanatory power to be worth retaining.
David wrote: <<[S]trict constructivists don't even believe that such an external reality exists. If one believes that solipsism is the totality of the universe, I guess they could never even talk about external conditions. But that is the type of radical, reductionistic type of stance that is more like religion than science>>.
I am not a constructivist myself—I find that approach to be a variation on philosophical idealism, with all its problems (the risk of solipsism being one; relativism and ultimately nihilism being others). But rejecting realism does not require one to veer all the way to the other pole. Existential phenomenology (specifically, that of Merleau-Ponty) starts from the premise that “internal” and “external” are, like all such dualisms (e.g., “mind” and “body,” the “immanent” and the “transcendent,” the “ideal” and the “real”) derivative constructs of an inherently unitary world of phenomena of which human beings are constituents (in the Gestalt sense of mutually constitutive parts of a whole, inseparable from each other without losing their essence). This is a remarkably hard thought to think (I’ve been working on it, on and off, for 25 years or so), but possibly the thought that leads to the aufhebung of many destructive dichotomies. Science? Probably not. Reductive or Religious? Definitely not
David Allen, 28 Febbraio 2006
Sorry about the confusion of "Gestalts."
What you call "the Gestalt sense of mutually constitutive parts of a whole, inseparable from each other without losing their essence" is an idea to which I wholeheartedly subscribe, so I guess we actually agree more than disagree. That idea is at the heart of a dialectical variety of family systems thinking about which my own metatheory revolves. Definitely not reductive or religious! The nice thing about it is that one doesn't have to give up the ideas of environmental contingencies OR unconscious processes in order to subscribe to it.
If a theorist believes that there are no unconscious mental processes, that theorist clearly has forgotten the experience we all have had of driving down a familiar highway lost in thoughts unrelated to the drive, only to suddenly realize that one remembers absolutely nothing about actually having driven the previous few miles. One can argue, however, about whether any given thought, impulse or emotion is truly unconscious in the Freudian sense or is merely pre-conscious or actively ignored.
Luca Panseri, 28 Febbraio 2006
In data 28 Febbraio 2006, Paolo Migone ha proposto di discutere un breve scritto di Sidney Blatt et al. che comparirà prossimamente sull’International Journal of Psychoanalysis nella rubrica “Letter to the editor”. Non essendo possibile pubblicare in rete l’intervento di Blatt (per rispettare i diritti editoriali), fornirò un breve riassunto per permettere di comprendere meglio il successivo confronto sul tema avvenuto fra Tullio Carere e Paolo Migone, pubblicato qui di seguito in data 28 Febbraio.
Mind the gap : On common round and pluralism.
Blatt e collaboratori riprendendo alcuni temi recentemente discussi da Wallerstein e Green (2005) sull’ International Journal of Psychoanalysis sottolineano l’importanza di due distinzioni fondamentali emerse in quel dibattito. La prima fra l’approccio nomotetico e quello idografico, la seconda tra un approccio prevalentemente intuitivo/interpretativo e uno prevalentemente neo-positivistico. Secondo Blatt e coll. in ambito psicoanalitico le giustapposizioni di queste modalità conoscitive sono da considerarsi non solo inutili ma anche false dal momento che ogni processo scientifico include sia procedure interpretative che di verifica .
Per Blatt la ricerca in psicoterapia va anzi intesa all’interno di una processo sequenziale nomotetico-idiografico-nomotetico che permetta di ampliare e approfondire in modo reciproco sia le conoscenze di tipo nomotetico che idiografico. Gli autori ritengono che attualmente il mondo psicoanalitico sia invece diviso in due filoni principali, il primo prevalentemente interpretativo e narrativo, il secondo prevalentemente neo-positivistico e probabilistico. Questi due orientamenti prevalenti si trovano in una situazione di opposizione e conflitto, incapaci di stabilire un confronto dialogico. Gli autori auspicano la possibilità di creare una situazione dialogica in cui le differenze delle due posizioni possano trarre arricchimento dal confronto invece che essere impoverite dal conflitto e dalla distanza.
Paolo Migone, 28 Febbraio 2006
Senza entrare compiutamente nel merito dei temi del dibattito precongressuale (non riesco ora trovare il tempo, e neppure le forze), colgo l’occasione per dire che mi trovo sempre più distante dalle posizioni portate avanti dal vecchio amico Tullio, il quale mi sembra che rischi di approfondire ancor di più, anziché colmare, il fossato che divide eventuali separazioni del movimento psicoterapeutico. Infatti Tullio dà per scontati mondi separati e in conflitto tra loro, mentre a mio parere si tratta di fraintendimenti. Non basta che un giornale come il New York Times (o se è per questo, qualunque altro giornale, autore o collega - cito il NYT perché il 26-2-06 è uscito un altro articolo del genere, questa volta di Adam Phillips) dica che il mondo della psicoterapia è diviso in due fazioni (es. una pro e una contro la ricerca empirica) per dire che questo sia “vero” (cioè anche in senso "reale", mentre è ovvio che a livello sociologico o nominale lo possono essere). Le cose vanno sempre capite nel loro contesto e interpretate. E soprattutto occorre saper dare delle risposte, trovare delle soluzioni che vadano al di là del ripetuto invito al dialogo o alla dialettica, che a mio parere lascia il tempo che trova (Blatt e colleghi ad esempio militano nel mondo che Tullio chiamerebbe "scientifico", eppure da sempre non vedono alcun conflitto con la componente chiamiamola così "umanistica" della psicoterapia).
Tra l’altro, come Tullio sa, la falsa dicotomia tra approccio nomotetico ed idiografico era stata già ben argomentata da Holt nel 1962, quando si scontrava con l’allora suo maestro Allport, fautore dell’approccio idiografico; vedi http://www.psychiatryonline.it/ital/documig6.htm ).
Tullio Carere, 28 Febbraio 2006
Caro vecchio amico Paolo,
chissà com'è che nonostante anni di discussioni e amicizia facciamo ancora così fatica a capirci. Vista questa perdurante incomprensione, mi sembra una buona idea chiedere un feed-back ai colleghi. È servito anche sulla lista SEPI internazionale, dove la vecchia amica Hilde ci è venuta in aiuto con un commento che si conclude con queste parole: " Having said that, I agree with you Tullio, that psychotherapy is a profoundly ethical practice, and- if I read you correctly- I agree with you Paulo, that morality has no place in it- other than as information about what the client believes or what she might be up against!". Sembrava infatti che tu confondessi l'etica convenzionale, cioè la moralità, con l'etica in senso proprio, cioè il senso naturale di giustizia (che appartiene al senso comune). Spero che l'intervento di Hilde abbia chiarito il malinteso, come spero che qualche collega italiano ci aiuti a chiarire quello che traspare dal tuo ultimo messaggio, in cui scrivi:
mi trovo sempre più distante dalle posizioni portate avanti dal vecchio amico Tullio, il quale mi sembra che rischi di approfondire ancor di più, anziché colmare, il fossato che divide eventuali separazioni del movimento psicoterapeutico. Infatti Tullio dà per scontati mondi separati e in conflitto tra loro, mentre a mio parere si tratta di fraintendimenti.
Tu dici che io do " per scontati mondi separati e in conflitto tra loro". Puoi citarmi un passaggio dei miei scritti in rete in cui faccio questo?
E aggiungi: “soprattutto occorre saper dare delle risposte, trovare delle soluzioni che vadano al di là del ripetuto invito al dialogo o alla dialettica”
Ti sembra che io non cerchi di dare delle risposte? Certamente le mie risposte sono diverse da quelle che dai tu, e anche da quelle che dà Blatt. Ma questo è il bello della SEPI: un luogo dove si possono dare diversi tipi di risposte, e poi confrontarle. Occorre però mettersi in uno spirito di confronto, e non di intolleranza per posizioni diverse dalle nostre. Se davvero vuoi confrontarti, ti faccio una proposta: prova a dire brevemente qual è la soluzione che tu proponi alla spaccatura del campo, io faccio altrettanto e poi speriamo che ci sia tra gli amici e colleghi italiani qualcuno che, come Hilde in campo internazionale, ci aiuti a dissolvere i nostri malintesi.
Paolo Migone, 28 Febbraio 2006
Caro Tullio,
tu dici: “Occorre però mettersi in uno spirito di confronto, e non di intolleranza per posizioni diverse dalle nostre”. Ritieni che sia io a mettermi in uno spirito di intolleranza? Se sì, in che modo?
Poi dici: “Se davvero vuoi confrontarti, ti faccio una proposta: prova a dire brevemente qual è la soluzione che tu proponi alla spaccatura del campo, io faccio altrettanto”.
Ma io avevo appena mandato un pezzo di Blatt et al. con cui dicevo di trovarmi in sintonia, e in quel pezzo vi erano precise proposte di soluzioni, con le quali peraltro tu dici di essere in disaccordo (hai scritto: “Certamente le mie risposte sono diverse da quelle che dai tu, e anche da quelle che dà Blatt”).
Resto quindi in attesa che tu spieghi le tue diverse soluzioni e ti saluto caramente
Tullio Carere, 28 Febbraio 2006
Paolo Migone ha scritto:
“ Caro Tullio,tu dici: "Occorre però mettersi in uno spirito di confronto, e non di intolleranza per posizioni diverse dalle nostre". Ritieni che sia io a mettermi in uno spirito di intolleranza? Se sì, in che modo?”
Capita a tutti, me compreso, di reagire emotivamente (con irritazione o sconforto) invece di fare qualche respiro profondo e riprendere pazientemente la posizione dialogica e confrontativa.
Poi dici:
“Resto quindi in attesa che tu spieghi le tue diverse soluzioni e ti saluto caramente”
Volentieri. Lo faccio subito riassumendo, sintetizzando e integrando cose già dette in questo dibattito (vedi in particolare il mio ultimo intervento sulla lista internazionale, in "Contributi II" di ieri).
1. Per effetto dell'integrazione assimilativa che avviene inevitabilmente, indipendentemente dal fatto che uno lo voglia e lo sappia o meno, esistono centinaia di scuole, migliaia di sottogruppi, e alla fine tante teorie psicoterapeutiche quanti sono gli psicoterapeuti nella stanza. La stessa conclusione vale per i diversi settori del campo, per esempio ci sono tante teorie psicoanalitiche quanti sono gli psicoanalisti nella stanza. L'esito paradossale dell'integrazione assimilativa è che ogni terapeuta è di fatto un terapeuta integrativo (in quanto per tutta la carriera assimila pezzi di altre teorie o tecniche sulla base teorica adottata negli anni della formazione - che peraltro è già un patchwork), mentre parallelamente il campo delle psicoterapie diventa sempre più dis-integrato e polverizzato.
2. Che ogni psicoterapeuta si costruisca la propria teoria su misura (secondo temperamento, storia, formazione, scelte) è un dato non solo inevitabile ma sicuramente positivo, perché uno dei fattori che maggiormente influenzano l'esito della terapia è il fatto che il terapeuta si senta a suo agio nel metodo che applica. D'altro canto questa estrema soggettivazione della nostra professione apre la strada a qualsiasi arbitrio e non è compatibile con gli standard di qualità e sicurezza che sono richiesti oggi a qualsiasi professione formativa o sanitaria. Di qui la sfida a uniformare la psicoterapia ai criteri scientifici che si applicano per la medicina: le metodiche psicoterapeutiche debbono basarsi su teorie corroborate dalla ricerca empirica, e le procedure specifiche debbono dimostrare la loro validità per i disturbi cui si applicano mediante studi clinici randomizzati.
3. La "sfida medica" è sacrosanta e anzi salutare per la nostra disciplina, perché ci responsabilizza costringendoci a scegliere. O ci arrendiamo alla medicalizzazione che avanza impetuosamente, riconoscendola come buona e giusta, o la rifiutiamo, ma proponendo un valida alternativa. Io ritengo che la medicalizzazione non sia una soluzione valida se non per situazioni particolari (un trattamento breve protocollare può essere l'indicazione di scelta per un servizio pubblico con un budget ristretto o perché è l'unica forma rimborsabile da una compagnia assicurativa). L'aspetto più problematico credo sia il presupposto che la psicoterapia possa essere studiata oggettivamente come qualsiasi altra specialità medica: in sostanza, l'idea che l'obiettivo sia quello di capire quali procedure producono quali risultati in quali tipi di pazienti. Come ha notato Westen, quasi tutta la ricerca empirica in psicoterapia si basa su queste premesse tipiche del behaviorismo anni Settanta, ma fortemente dissonanti con la realtà della psicoterapia come effettivamente si svolge nella pratica, come descritto al punto 1.
4. I risultati degli studi clinici randomizzati hanno una "validità esterna" (cioè un'applicabilità nella pratica reale) molto modesta, perché nella realtà le condizioni sono di regola molto più complesse di quelle semplificate negli studi sperimentali, e perché i protocolli sperimentali non sono applicati con un rigore minimo nella pratica reale - se d'altra parte lo fossero, si rischierebbe l'"abuso teoretico", cioè la forma di abuso paragonabile a quello sessuale consistente nel costringere un paziente a sottomettersi alle aspettative teoriche del terapeuta (l'esatto contrario del dialogo terapeutico). La realtà clinica è molto lontana dalle astrazioni della ricerca sperimentale. È una realtà che vede di fronte un terapeuta che ha un suo stile di lavoro unico e un paziente che ha esigenze uniche. L'interazione che ne risulta è sempre diversa e imprevedibile, ma è caratterizzata da modalità ricorrenti o regolarità tipiche della relazione paziente-terapeuta, indipendentemente dalle teorie e tecniche applicate.
5. E' precisamente l'esistenza di regolarità tipiche o fattori comuni a ogni relazione psicoterapeutica l'elemento unificante, il terreno comune a tutte le pratiche psicoterapeutiche, indipendentemente dalle teorie professate. Una integrazione teorica è già problematica se riferita a due teorie incompatibili ma sufficientemente definite e coerenti, ma è semplicemente impensabile se riferita alle centinaia o migliaia di teorie che polverizzano il campo psicoterapeutico. Per questo l'unica integrazione possibile del campo è sul terreno pratico, cioè il terreno comune sul quale si trovano i fattori comuni e su cui è possibile una comunicazione trans-teoretica tra terapeuti. Su questi fattori è stata e deve ancora essere fatta molta ricerca, ma una cosa dovrebbe essere chiara: la ricerca empirica come è comunemente intesa non è adatta a investigare questi fenomeni. Per il semplice motivo che questi fattori non sono "ingredienti" o "procedure" che uno possa "manualizzare". Non sono comportamenti osservabili e registrabili del terapeuta, ma esperienze del paziente. Per esempio ogni terapeuta, di qualsiasi scuola, deve dare risposte sufficientemente buone al bisogno di "base sicura" presente virtualmente in ogni paziente. Ma non c'è modo di sapere che cosa sarà rassicurante per un dato paziente in una data seduta. Per uno sarà rassicurante un setting molto rigido, per un altro un setting molto flessibile. Quello che conta qui non è quello che il terapeuta fa, ma quello che il paziente esperisce. E le esperienze non possono essere osservate dall'esterno. Possono essere investigate nel corso della seduta, come è ovvio, ma anche con questionari post-seduta integrati da note scritte del paziente e del terapeuta. Questo materiale permette di monitorare e documentare il processo, e di correlare il processo e l'esito. Se l'oggetto della ricerca non è il comportamento, ma l'esperienza, la ricerca non deve essere sperimentale, ma documentale.
6. Noi divergiamo nell'integrazione assimilativa, ma ci ritroviamo sul terreno comune, nell'approccio dei fattori comuni che può essere propriamente chiamato integrazione accomodativa. Possiamo osservare i bisogni e i fattori terapeutici comuni e facilitare la loro emergenza, espressione e sviluppo, nella misura in cui sappiamo sospendere preconcezioni e aspettative, memoria e desiderio, e sintonizzarci con il processo che si sviluppa per logica propria. Troppa integrazione assimilativa rende il terapeuta auto-centrato e sordo alle esigenze del processo, troppa integrazione accomodativa è dannosa per la coerenza del terapeuta. La consapevolezza di questa fondamentale polarità integrativa facilita la ricerca del giusto equilibrio, appropriato alla specifica situazione terapeutica. Questa prospettiva di integrazione assimilativo-accomodativa, che combina le esigenze di differenziazione e unificazione del campo, è l'alternativa che propongo all'integrazione basata sulla ricerca empirica (sostenuta esplicitamente dal nostro amico Gianni Liotti). Il vantaggio di questa prospettiva è che lascia alla singola coppia terapeutica la massima libertà di interagire al di fuori di qualsiasi protocollo, ma la vincola all'obbligo di produrre materiale documentale che permetta di correlare i risultati ottenuti al processo, salvaguardando in tal modo le esigenze irrinunciabili di controllo della qualità e sicurezza del trattamento.
7. Non credo invece che a queste esigenze risponda adeguatamente l'approccio "nomotetico-idiografico" di Blatt e colleghi. Lo stesso Holt, che tu citi a sostegno, è molto netto nel dichiarare che queste parole (nomotetico e idiografico) "sarebbe meglio se … scomparissero dai nostri vocabolari scientifici", mettendo in guardia dalla tentazione di fare "una combinazione o un miscuglio di procedimenti nomotetici e idiografici" - precisamente quello che Blatt fa.
Soprattutto Holt mette in guardia da pasticci derivanti dai tentativi di sintetizzare teorie o approcci incompatibili (la cosiddetta "integrazione teorica"), proprio i pasticci in cui si caccia Blatt con il suo intento di far dialogare due culture contrapposte, "one culture more interpretive and narrative in orientation, the other more neo-positivistic and probabilistic". Come sai bene, anch'io cerco di favorire il dialogo tra le due sponde, ma non certo su quella base. Tra un narrativista e un positivista non può esserci che un dialogo tra sordi, se si immagina che il dialogo possa avvenire sulle basi proprie di ciascuno - o come si esprime Blatt, attivando "nomothetic-idiographic-nomothetic cycles". Il dialogo, per quel poco o tanto che è possibile, quando è possibile, avviene precisamente nella misura in cui i dialoganti si schiodano ciascuno dalle proprie fissazioni teoriche per ritrovarsi su quel terreno comune sul quale la comunicazione è possibile. Più specificamente, gli approcci "idiografico" e "nomotetico" dovrebbero essere considerati (come fa Holt) delle esasperazioni o forzature rispettivamente del pensiero intuitivo e del pensiero razionale, che sono funzioni naturali comuni a ogni essere pensante. Per i Greci la dialettica tra nous (intuizione) e diànoia (razionalità) è la base di ogni processo conoscitivo. Su questo terreno comune noetico-dianoetico possiamo sempre ritrovarci se vogliamo comunicare, mentre non ci ritroveremo mai se pretendiamo di far valere come universali quelli che sono solo modi particolari e specialistici di intuizione e razionalità - per esempio se pretendiamo di imporre a tutto il campo psicoterapeutico i metodi della ricerca quantitativo-statistica, estranei alla clinica. Viceversa il dialogo tra clinica ed ricerca può avvenire sul terreno comune della produzione di materiale oggettivo (registrazioni, questionari, note scritte) necessario per documentare il processo e correlarlo con l'esito. Qui può avvenire l'incontro tra lo scienziato locale e la ricerca generale, mentre la ricerca di tipo medico, degli studi clinici randomizzati, non fa che approfondire il solco tra clinica e ricerca producendo la spaccatura che è sotto gli occhi di tutti.
Mi aspetto, caro Paolo, che come io ho criticato la proposta di Blatt, con cui tu ti trovi in sintonia, tu faccia ora altrettanto con la mia; e che i colleghi siano testimoni partecipi e soprattutto contribuiscano attivamente a un confronto pacato e sereno.
Paolo Migone, 28 Febbraio 2006
Caro Tullio,
ti ringrazio della risposta, che mi conferma l’impressione che avevo: tu continui a estremizzare i due poli, quello della ricerca e della clinica, facendo ad esempio della ricerca statistico-quantitativa una sorta di bete noir che non potrà mai andare d’accordo con la clinica di tutti i giorni. La ricerca che tu chiami “documentale” e che tu prediligi, ad esempio, non è altro che un tipo di ricerca empirica, da affiancare ad altri tipi (nessun tipo conduce alla verità, neppure la ricerca clinica conosce la verità, che per sua natura è in conoscibile, vi sono tanti metodi di conoscenza). Trovo che il metodo proposto da Blatt et al. (che poi non è niente di nuovo sotto il sole) sia praticabile, mentre mi sembra che non sia così facile il “dialogo” che tu invochi tra due poli che tu stesso peraltro definisci incompatibili (se non con l’assenza di memoria e desiderio o epochè che dir si voglia, metodo che come sai per me rimane un pio desiderio, e inoltre mi sembra essenzialmente un ossimoro nel senso che un metodo si avvicina all’altro se cambia natura, cioè se non è più lui: bella forza!).
Hilde Rapp, 1 Marzo 2006
Allan wrote:
<<I understand theories as well-organized explanatory frameworks, which can be applied to a range of phenomena and which are capable of generating either hypotheses that can be tested empirically or truth-claims that can be evaluated rationally>>.
I agree entirely, a theory needs to be able to organize observations, generate lawful or at least orderly relations between them, predict what novel observations would be expected to fall under the scope of the theory, be testable empirically, or capable of rational justification via logical argument.
It was precisely this understanding of the role and nature of theory which led to the evolution of the assimilative (- accommodative) integration (pre?) paradigm.
The debate was/is (see Messer et al 2000/2001? the JPI assimilative integration issue) about what transforms or re-descriptions of a borrowed technique, or what reformulations of a theoretical term, might be possible so as to allow it to be integrated into the theory which informs our practice without distorting either theory or praxis in any serious way…
There are clear exclusion criteria at stake which have been variously articulated in our literature and which constrain the principled ( here Tullio’s term is very apt) transposition and inclusion of new thinking and ways of working, whatever their origin, into an espoused theory if this is to retain any meaningful family resemblance to the theory in use by a practitioner.
Hilde Rapp, 1 Marzo 2006
Allan wrote:
<< Existential phenomenology (specifically, that of Merleau-Ponty) starts from the premise that “internal” and “external” are, like all such dualisms (e.g., “mind” and “body,” the “immanent” and the “transcendent, ” the “ideal” and the “real”) derivative constructs of an inherently unitary world of phenomena of which human beings are constituents (in the Gestalt sense of mutually constitutive parts of a whole, inseparable from each other without losing their essence). This is a remarkably hard thought to think (I’ve been working on it, on and off, for 25 years or so), but possibly the thought that leads to the aufhebung of many destructive dichotomies. Science? Probably not. Reductive or Religious? Definitely not.>>
To think of our being in the word and of the world in which we are and do as “mutually constitutive parts of a whole, inseparable from each other without losing their essence” is indeed “a remarkably hard thought to think”. This also exercised Freud more than somewhat – and indeed, Bion. I have (reluctantly) come to the conclusion that we can, in certain meditative states which include the psychoanalytic art of ‘free association’, and ‘mindfulness’ in cognitive behaviour therapy , experience wholeness and unity.
I do, however, not know how to convey this experience of unity in the form of narrative discourse, nor, in the strict sense of the word, do I know how to think such a thought- my mind seems to be too small for that. I therefore contend myself ( reluctantly) with recognizing and respecting that different disciplines and their different epistemic foundations and methods of enquiry have come about in order to addressed this task in piecemeal fashion so as to make thoughts smaller and thus thinkable in a coherent way.
The ground map for my four quadrant meta- framework therefore sets out four different starting points for a collaborative and integrative endeavour at understanding ourselves and our world in ways useful for the practice of psychotherapy. I suggest that we draw on the wealth of historic traditions which define different universes of discourse, bodies of knowledge, wisdom, experience, practices, and peer derived conventions that give shape and content to each of these ( notionally) four families of logic of inquiry into:
1. subjective experience ( phenomenological)
2. collective meaning making ( hermeneutic)
3. human development (evolutionary/ human sciences)
4. understanding society and environment (complexity/ living systems approaches ).
Each epistemological enterprise addresses a particular area of enquiry particularly well and looses its force and scope in relation to another.
As integrative therapists we need to be clear an honest about which of the following two kinds of endeavours we are engaged in. the making meaning of our experience or searching for knowledge and explanations. We need both to practice. We may be temperamentally inclined to wards one or the other. We pick clients who benefit more form our intuitive wisdom and skill, or clients who need more direction and systematic support. All the same our art, craft and science relies on both scientific research and emotional intelligence…
1. Sharing Experience and Making Meaning for the Sake of the Client’s Wellbeing ( largely informedby 1phenomenological, and 2hermeneutic endeavours: reflection, contemplation, intuitive understanding and interpretation)
Seeking a means for pointing to an experience so that we can share something about it that makes us more compassionate, more sensitive and observant, more humble and yet more daring when we grapple with dark forces, lies at the centre of our praxis. We are working with our capacity for violence, our capacity for deception, but also our passion for what is beautiful and erotic and our hopes and fears and our search for truth.
This is the crux of psychotherapy – something happens in the consulting room between the client and the therapist which is actually ineffable because we cannot unpick it from the context of the living and lived experience without it loosing much of its meaning and its significance for change.
We may call it transference, projective identification and so on if we are analysts, empathy,mirroring if we are person centred, modeling if we are behaviour therapists, parallel process if we come from Gestalt, shaping if we are learning based, resonance , following and leading in NLP, experiencing, if we are experiential, therapist and client factors in the common factors approach, and the relationship, if we are cautious about avoiding what may sound like jargon and so on.
We work with these phenomena and we know that they are essential to therapeutic outcomes.
Although he abandoned this position later, Wittgenstein once said something like “there are things that can be said, and things that can only be shown- and about that of which we cannot speak we should remain silent…” but then he was a philosopher. We as therapists (must?) dare to speak (clumsily) about those ineffable things because we are practitioners and not logicians…We need to achieve what Jerry Bruner calls joint deixis, that is a line of gaze that points us to the therapeutic experience we want to share, collaboratively seek to understand so that we may find ways of working more effectively for the sake of the client’s wellbeing.
The best we can do is to circumscribe what it is about the whole that we can experience but not speak about
Adorno recommended an essayistic circumlocution of the ungraspable object of our enquiry. Like the poet, we might encircle what we are after enough to narrow down where we should look- with inner and outer eyes: out quarry is in that symbolic thicket over there! Merleau Ponty or Husserl language this enterprise differently, but I think they are after the same thing. Long live epoche, the inevitable adhesions of preconceptions not withstanding, and may the cloud of unknowing shield us all from hybris…
Perhaps we need to bear our relative smallness and ignorance and accept that these ineffable experiences at the heart of the therapeutic encounter cannot be theorized in the sense of making the sort of “ truth-statements” that should be foundational to a “proper” scientific theory. Perhaps they can only be “theorized” in the original Greek sense of the word which refers to a way of seeing linked to an exercise in aesthetics and ethics rather than to an effort after explanation in a natural science sense. Here we are after an activity, a verb, to find ways of seeing and interpreting reasons and justifications, rather than that construct a systematic edifice which accommodates the relations between causes and effects?
We can speak about things, but not of them, but we can show phenomena ( appearances)…
2. Picking out and languaging an aspect of our experience to generate knowledge( largely informed by 3. evolutionary/human sciences and 4. living systems approaches: observation, description, explanation, treatment and prevention)
We endeavour to generate knowledge by become more competent at picking out an aspect of that whole and to language it in such a way that we come to know something new and specific about this experience which does not depend for its understandability on the unmediated access of an embodied experience or the context in which it appears. The experience is mediated, abstracted and symbolically expressed (Hegel’s Vermitteltheit). Although we loose a lot in the transmission, what we can say still makes enough sense to be useful and informative to others who work in the same area- and if we are lucky it makes sense to people at large, at which point it may approximate to knowledge.
Observation and Description: We seek to describe in relatively unambiguous language any observable effects of these clinical phenomena such as resonance, f critical moments, or change events.
We want to specifically exclude what we may know through our imaginative participation in the privileged experience in the actual therapy situation. We want to objectify and decontextualise that which we wish to study. Such objectivising approaches are nonetheless not ‘theory free’.
There are no ‘data’ (givens), everything is interpreted, but the theory in this context is a sort of contamination.
We aspire to translate natural language terms with all their semantic fuzziness into formal language terms – we deliberately set out to create jargon that is stripped of ambiguity because the word is not normally used outside the scientific arena for which it has been formulated and so does not acquire contextualised meanings.
We admit that we cannot wholly succeeded- we are self reflective- but we continue to try to make something like DSM3R or DSM4 or ICD 10 as clean and descriptive as we can./ We do our best to categorise and classify the observable effects/ symptoms of ineffable psychic and relational processes in a descriptive way. We aim to set signposts that reliably point us to roughly the same place in the forest of symbols.
Observation and Explanation: We want to be able to identify the object of our inquiry as accurately as possible. We want to be able to compare one client with another on the basis of clear selection criteria. We want to map comparable patterns in client behaviour. We want to examine their relationship to the clients life conditions. We want to see whether certain effects are reliably associated with certain causes. What makes people vulnerable or ill? What is the natural history of a disorder?
Treatment and Prevention We want to know what the therapist and client do together to see who works well with whom and who does not, and what works and what does not, and what sort of therapist behaviours work with what sort of client difficulties.
We endeavour to specify therapeutic procedures in the form of treatment manuals so we can test certain hypotheses about what facilitates or hinders the occurrence of experiential and relational phenomena which we believe to be associated with change. We need to be able select clients who are well described by a particular label in a common classificatory system. We need to ascertain whether therapist A and therapist Z are both performing the action specified by their espoused theory as effective and we need to be sure that this is significantly different from what therapist B and O are doing who espouse different theory. We want to know which method is more effective.
We also want to study what factors can to prevent distress or disease, so that we can help to ameliorate it better and faster.
Processes We are curious to identify behavioural markers for psychic events and processes which we cannot directly access, but which we know from our own experience as practitioners, take place. There- that look- that inclination of the head- that silence- that breath- seems to correlate with a critical event- does it? The use of imagery, metaphor, laughter precedes a shift – is this a pattern. ?
Here comes the rub –( or is it an invitation to integration and learning ?) :
We can only meaningfully pick out an aspect of therapeutic experience for this kind of objectivising scrutiny because, (provided we are practicing therapists), we already havedirect – presentational-(see also Shannon’s excellent arguments for this) experience of the whole from which we are now picking out a part for our special attention.
We are in the same business. Although our experiences are not exactly the same, they are often similar enough for us to be able to recognize our own experience in someone else’s account, description or analysis of what occurred in a session or treatment.
This is how we learn from other people’s experience and how we come to enrich our own. We have the Aha-experience of yes! this is what happened in my session, yes: this is a useful interpretation of something I have been struggling to understand, oh good she also thinks that this is a good technique…
This prior orientation allows us to understand where a given linguistically or symbolically mediatedre-presentational (and probably logically incomplete) sentence or description is pointing. We may recognize our client in a particular DSM description and we may find that a clinical guideline for how to work with such a client illuminates for us what to do better tomorrow.
The guideline may give us a road map for setting up the facilitating conditions to give space to and bring about a particular therapeutic experience which replicates the kind of experience the clients who were part of the sample that was used to construct the guideline may have hade that may have helped them to change.
The map is not the territory : description is no substitute for experience
The writer of a cookbook or a therapy manual doesn’t claim that it makes you an inspired or competent cook or therapist, it doesn’t create an intimate atmosphere, it doesn’t equip you with the sense of smell that tells you that something stinks, it doesn’t regulate your flame or prevents you from burning the meal. It just describes, how you might use certain ingredients to create a constituent of the whole experience – the meal- not the encounter within which the meal plays a part, nor whom to invite. Nor does it forbid you to alter the recipe. It merely describes...
Whether it helps our praxis to use a guideline or to copy another colleagues technique is partly a function of whether we are a ‘good cook’, whether this is the right time, the right chemistry and whether we have the right ingredients for a therapeutic experience to arise and whether we have to wit to recognize a change event for what it is when it does occur.
I have not really met anyone within SEPI who confuses the map ( symptom checklists of whatever kind – or the recipe, ie descriptions of observable relationship events, or behavioural markers of features of an emotional landscape) with that territory where Virgil dares to walk with the leopard!
I also I think we do, on the whole, know the difference between this leopard and a paper tiger quite well- thank you to all within SEPI!
Both the effort after meaning and the effort after knowledge are paths to understanding within a civilizing endeavour- to bring out the best in us as individuals by way of self realisation and self definition on the one hand and to socialize us to be fit for building relationships as global citizens through attunement, self restraint and co-regulation in the service of joint action… on the other.
Experience without science is dumb (speechless) and science without experience is dead (lifeless ).
I apologise that I needed so many words to mutter this. We can, as Allan wrote, only ever “ asymptotically” approximate to the truth.
Tyler Carpenter, 1 Marzo 2006
I agree with your general slant on things, Tullio. Sorry I can't join you for a Chianti or cappuccino in the near future, but when I'm in the neighborhood I'll bring a home brewed beer (I just finished making a Belgian Tripel and will bottle a Barley Wine April 1st).?]
More particularly:
Sometimes group process is muddled with paradigm clashes. I would add to the concept of a disciplined mind, the zen concept of no mind. Sometimes even disciplined minds run into subtle distinctions that are obstacles in the path to a larger understanding of the topic at hand. The late Chogyam Trungpa Rinpoche's concept of "spiritual materialism" is related to the idea that individuals, even bright ones, can fetishize (?sp.) concepts (especially ideals) and then get caught up in the detritis (sp?) of certain distinctions and emotional reactions.
As a former academic - medical school research team member, I have a great appreciation for the role that disciplined study can bring to any orientation that one chooses, as long as the data and context are clearly understood. Here I suspect I think similarly to Tullio. ESTs can also simultaneously be great tools for the apprentice and journeyman and patient on an individual path of change, or if tweaked by the expert, an adjunct to systems interventions or psychotherapy broadly conceptualized. I would add to the concept of treatment as ethically based, that of evolutionary and adaptive biology. If the applied values didn't have survival value for the
individual and the group, there would be little or no purpose or effect in applying them. When you add biology-chemistry-neuroscience to the pot, things begin to bubble and savory smells emerge.
Hilde,
I would add, that particularly when we begin to drop the need to define all in one framework, different levels of systems often provide their own vocabulary and framework that complements other levels. When each participant (or group) deals with the issue as they see it and it (their conceptualization) is perhaps tweaked a bit to function both for them and in doing so for the systems, then the whole may lumber on adaptively without the impediments that separate conflicting vantage points can often bring to what is essentially a unitary process, regardless of our attempts to name it and its constituent elements. What I am struck by again and again is the lack of understanding different groups have of each other and how often just providing common ground, without exchanging worldviews, is all that is needed for good enough adaptations to become emergent.
Dear Paolo,
On ethics I'm not sure that relying on ethics is anymore or less useful than relying on theories of therapy (especially given their partial correlation with one another). Ethics are often based on precisely what you suggest makes them unworkable as a foundation for treatment, namely the different schools of reasoning that govern the ways in which one may integrate the various common principles that one may invoke when addressing a common problem. The approach is both nomothetic and idiographic and this dual nature is built into the body of the discipline.
Tullio Carere, 2 Marzo 2006
George Stricker wrote:
<<My preference is for an assimilative approach to integration, in which a preferred theory is maintained and techniques from other approaches are assimilated. However, the challenge after successful assimilation is accommodation - changing the home theory so that it can accommodate a technique that originally would not have been suggested by it. Is accommodation possible or must the theory be discarded in favor of a synthesis? I don't know, and that is the challenge we face.>>
George,
it is wise to prefer the inevitable. In my view we are all assimilative integrationists, inasmuch as we all start with a theoretical base that we form in the years of our training, and go on building on that base through our entire professional life. When we assimilate something, we have to change more or less our home theory to accommodate the new thing, as you point out. As a result, in the course of time the building grows into a mixture of the original theory unmodified (which already is an idiosyncratic collection/selection of the original inputs), the original theory modified to accommodate the assimilated foreign bodies, foreign bodies not really assimilated but hanging around in a more or less eclectic way. The bottom line is that we have hundreds of schools, thousands of subgroups, and virtually as many psychotherapeutic theories as there are psychotherapists in the room. The paradoxical outcome of assimilative integration is that the individual psychotherapists become more integrated, to the extent that they integrate into their original approach modes that originate elsewhere, while at the same time the psychotherapy field becomes more and more dis-integrated.
We are all very happy with our idiosyncratic assimilative integrations, as we also are more or less painfully aware of the resulting disintegration of the field, and struggle towards some form of integration -- this is why SEPI came to existence, I believe. I am not as optimistic as David about the feasibility of a theoretical integration between, say, two incompatible but reasonably coherent theories like psychopharmacology and psychoanalysis (if psychoanalysis were a coherent theory, which is not). But it should be clear that the very idea of integrating hundreds or thousands of incompatible and incommensurable (and incoherent) theories is absurd. This is why I say that the only possible integration of the field happens on the pragmatical ground, i.e. the common ground where we find a number of common factors, and where a communication among us, independent of our theories, is possible.
Sure enough, research has been done, and more research must be done on common factors. But I dare say that empirical research as it is commonly meant (on the blueprint of medical research) is not very fit for investigating common factors. For the simple reason that common factors are not "ingredients", or "procedures" which one can "manualize" (what can an empirical researcher do without manuals, or at least precise enough guidelines?). They are not behaviors of the therapist (observable, recordable) -- they are experiences of the patient. For instance, we know that every therapist, of whatever school, must respond properly to the basic need of secure base virtually present in all patients. But there is no way to know in advance what will be reassuring for a given patient in a given session. One will feel at ease in a rigid setting experienced as persecutory by another who will feel secure in a flexible setting. Experiences cannot be observed from the outside, yet they can be investigated not just in-session (which is obvious), but with post-session questionnaires, integrated with written notes by both patient and therapist. This material permits to monitor and document the process, and to correlate process and outcome. If the object of research is not behavior, but experience, the research should not be experimental, but documental.
We diverge among us inasmuch as we integrate in the assimilative mode, we converge in the common factors approach, which could also be properly called accommodative integration. We can observe common needs and common therapeutic factors, and facilitate their emergence, expression and development, to the extent that we know how to bracket out our theories and get tuned in the process that develops in its own right. Too much assimilative integration makes the therapist self centered and insensitive to the process, too much accommodative integration is detrimental to the therapist's coherence. "Ideally, one might expect to see a fairly even balance between assimilation and accommodation, with neither predominating to any great extent". Paul wrote this sentence with reference to individual treatment, but it also applies to the field as a whole.
Barry Wolfe, 2 Marzo 2006
Hello All,
I would like to weigh in with a vote for working toward a unifying conception of psychotherapy, even though this may strike us now as an unrealisable goal. There are two reasons for this: 1) there is a lot of theoretical redundancy in our various theories of psychotherapy and in the disorders they treat and 2) some theoretical propositions within each theory are just plain wrong. For example, in my recent review of the various extant theories of anxiety disorder and their treatment (Wolfe, 2005)*, I found that psychodynamic, cognitive-behavioral, and humanistic/experiential theories all argue that we are ultimately attempting to bring about change in tacit internalized psychic structures regardless of the theoretically-based terms we give them (i.e. unconscious character traits,
cognitive schemata or tacit emotion schemes). Secondly, psychodynamic theories need to "accommodate" the fact that exposure therapies can effect symptomatic improvement in virtually all of the anxiety disorders, while behavioral theories need to accommodate the fact that there are tacit
dimensions to anxiety disorders (even phobias) that are responsible for both the development and maintenance of these disorders.
These are just single examples of what I believe is a fairly wide-spread need for trimming theoretical redundancy and engaging in a significant amount of theoretical accommodation.
George Stricker, 3 Marzo 2006
My response incorporates a response to an early post from Allan as well as yours Tullio. I agree that my approach is within the realm of normal science, to use Kuhn's term, and also that psychology (not just psychotherapy) is still pre-paradigmatic. My preference for normal science rather than Allan's Nietzschean solutions (theorizing with a hammer) is based on my pessimism about the approach that so many others are favoring. Physics, which is far in advance of us, and is paradigmatic, has been searching for a Grand Unified Theory in vain, at least to date, and that does not encourage me as to the prospects for psychotherapy achieving success at a GUT. In the meantime, we still have to serve our patients, and the best avenue, in my mind, is through assimilative efforts and a search for common factors, probably located in a region at a level lower than theoretical. By the way, Tullio, I wish we all were assimilative integrationists, but I think many people function as eclectics, free from theory, although I've never been enamored of that approach.
Zoltan Gross, 5 Marzo 2006
How does one convince others that the earth rotates on its axis while traversing its orbit around the sun, when it is important for them to know the sun rises in the East and sets in the West?
I agree with George Stricker that both psychotherapy and research psychology are in a pre-paradigmatic stage of theoretical development. However, with the introduction of information from neuroscience, I am more hopeful than he is about the prospects for the creation of theory of personality that is both researchable and clinically useful. At present, theorizing about personality is an outside-in way of looking at it. We observe the behavior and the reported experience of people with common sense cognition that is linearly and sensorially formatted. This information is then passed through lens of Western cultural tradition and belief. As a result we are greeted with descriptions of personality spoken in different "languages" (paradigms) using the same words but which have different meanings. There are no consensually agreed upon definitions about such words as personality, person, self, emotion, or cognition. Furthermore, none of these terms have theoretically elaborated relationships with one another. In effect, I believe we have been anthropomorphizing cerebral operations based on commonsense cultural biases. I find it difficult to believe that "meaningful" assimilation can readily occur when this epistemological barrier exists.
Early on in my practice I realized that common sense contributed more to my confusion than to psychotherapeutic growth. When people returned their "repressed" to me I found that they were "returning" what I had asked them to return. Nothing much happened with that exchange. The operation of the Pleasure Principle was rarely seen except when it came to ice cream cones. Plato's and Freud's hoped for sovereignty of reason over passion didn't exist. Reason was always swept away when the storms of passion, anxiety, depression, or pain passed over the landscape of the individual's personality. As I came to see how congruent the dualities of personality operations were to the doubly dual structure of the brain, I abandoned "common sense" as a guide to my work. I found my self engaging in some of the wisdom of the Theater of the Absurd and the Sufi and Zen mystical traditions. The differences in information processing of the left (linear) and right (nonlinear) hemispheres and anterior ("executive" and emotional - nonsensory) and posterior (sensory) lobes helped me to better understand the relationship I was having with the people with whom I was working Since personality operations are largely relational and are nonsensory it is extremely difficult to describe them in common sense formats. Instead, applying Averill's idea about functional analysis to cerebral operations (an inside-out way of looking at personality) it is possible to create a theoretical paradigm that can accommodate the nonlinear (relational) and
nonsensory (selves and emotion) dynamics of personality that is both researchable and clinically useful. We are now on the threshold of the creation of a new psychological paradigm. The achievement of Freud's Scientific Project is now possible. With it, we can escape the limitations of "folk" psychology upon which we currently rely. It is not enough to know that the sun rises in the east and sets in the west. This belief could lead us to believe that we are at the center of the universe. We have a richer and less limiting understanding of where we are in it, when we know about the dynamics of our orbital relationship to the sun. The wish I have just outlined hasn't happened yet, but I believe that it can.
Allan Zuckoff, 6 Marzo 2006
Tullio wrote:
<< For instance, we know that every therapist, of whatever school, must respond properly to the basic need of secure base virtually present in all patients. But there is no way to know in advance what will be reassuring for a given patient in a given session. One will feel at ease in a rigid setting experienced as persecutory by another who will feel secure in a flexible setting>>.
Tullio,
Each of the three statements above is a) theory-specific, and b) empirically testable. Manuals are much less limiting (and limited) than you suggest, and it would not be that difficult to do a study in which one group gets therapy that is attuned to these polarities and adjusts accordingly, while the other gets a one-size-fits-all approach. And the results of the study would allow us to go from assertion to research-supported positions on these critical questions.
Hilde Rapp, 6 Marzo 2006
Dear Allan, dear Tullio,
Such research exists- especially within Shapiro paradigm of altering the sequence in which conversational- relationship focused interventions and cognitive behavioural interventions are delivered – Members of the Society for Psychotherapy Research in the UK can help pinpoint where particular studies may be found…
Allan Zuckoff, 6 Marzo 2006
Hilde wrote:
<<The ground map for my four quadrant meta-framework therefore sets out four different starting points for a collaborative and integrative endeavour at understanding ourselves and our world in ways useful for the practice of psychotherapy…>>
Dear Hilde,
Your post was challenging and complex, and I found much to admire in your views as well as in the humanity that spoke so clearly through them. I must, however, have another go at challenging the epistemological assumptions of your meta-framework.
Much of your post centered around the dichotomy of the “subjective” and the “objective,” understood through a traditional philosophy of science. In this model, there is a “subjective” realm of immediate experience that cannot be directly accessed by others, and an “objective” realm of mediated knowledge that can. Of course, these categories also correspond to the traditional ideas of “mind” (that which is private) and “body” (that which is public).
I would like to propose that this model, universally accepted since Descartes, is precisely what has led to all kinds of conceptual trouble and needs to be jettisoned. That is to say: because we are “incarnate consciousness” or “animated bodies” (the two terms mean exactly the same thing), mind and body, subjective and objective, can never by separated without doing violence to reality. (And the trouble has not only been conceptual; once we dichotomize mind and body, we prepare the way for the demonization of the erotic body that has plagued the West for the past couple of millennia). Our experience is always mediated and accessible to others: not, as the poststructuralists and anglo-analytic philosophers after the linguistic turn would have it, because we are born into and formed by language (though we are, in part), but because we are flesh, and we recognize ourselves in the flesh of others (Merleau-Ponty called this the chiasm, or intertwining), and the meanings we perceive are not merely “imposed” by us (because, then, how would we ever know whether we are imposing the correct meanings?), but inherent in reality. What is, is autochthonously organized; we are part of what is; and we perceive that organization because it is there, and because our perception is a constituent of its coming-to-be.
So, one might reasonably wonder, what are the implications of all this wooly philosophizing for psychological and psychotherapy research? Well, one major implication is: we need to stop using the term “phenomenological” as a synonym for “subjective.” Empirical-phenomenological research is not merely the elaborate description of subjective experience. It is a (human) scientific method for accessing the real essences of things, the meanings that inhere in phenomena (which is all there is). It provides analyses of descriptive data that allows us to “come to know something new and specific about this experience which does not depend for its understandability on the unmediated access of an embodied experiencer or the context in which it appears.” It does not, of course, provide us with “objective” knowledge—but only because the very idea of “objectivity” would require that we could view the world from a God’s-eye view, and because, once we “decontextualize that which we wish to study” it is no longer what we wish to study. (What is, is organized as figure/ground, theme/horizon; the theme does not exist without the horizon, nor the “object” outside its context.) It does, however, provide us with knowledge that can be replicated (or falsified), and allows us to test hypotheses and make truth-statements.
It does not, it is true, allow us to speak of “cause” and “effect”—and, as problematic as those constructs are within a phenomenological framework (and within a quantum physics framework, for that matter), we clearly do wish to be able to make such statements—we need to conceptualize the world in these terms (at least for now). So research along the lines of our traditional understanding of science is needed, as well. RCT’s tell us part of what we want to know—does doing therapy one way bring better outcomes than doing therapy another way?—and, pace Tullio, it is not hard to separate studies done from a standpoint of openness to any outcome from studies (like those of the Vatican “scientists” Tullio invokes) whose outcomes are predetermined. (All “empirical” research is not created equal.) It’s just important, I think, that we recognize that this is not the only path to genuine knowledge—and that the knowledge we gain via methodologically sound empirical-phenomenological analyses may ultimately tell us at least as much about what we most want to know.