Dibattito precongressuale
2° CONGRESSO S.E.P.I. ITALIA Firenze 24-26 Marzo 2006
Pagina 4
Tyler Carpenter, 6 Marzo 2006
I suspect that the phenomenon that Tullio is referring to is more subtle than the research solution you are proposing, Allan. Evidence of such security is highly idiographic and relative to not only the specific relationship, but such factors as timing, nature of issues being addressed, etc. Security itself is dimensional, as well as being both state and trait-like. Are we talking Ronnie Laing's "ontological insecurity" - his philosophical labeling of the phenomenological state of biomedically based psychoses, the individual's willingness to risk insecurity because of their faith in the security of the relationship, etc.?! What constitutes a multi-dimensional dependent measurement which both reflects the levels of system in the individual, but also allows for comparisons across and within
groups? I'm not being a nihilist here, and I certainly appreciate good research, but we don't need more studies looking at changes in verbal behavior linked to theory and interventions. I remember years ago reading Walter Mischel's (I think) conclusion that one of the flaws of analytic research was that in order to examine concepts with real construct validity, one was forced to stay close to the surface so to speak.
Although I suspect that high-speed computers and chaotic models used for weather and economic forecasting would be one entry into more sophisticated research, we would not be mired in the lose-lose discussion about ESTs vs. dynamic models if we had something better and transtheoretical to examine. This stuff is hard to think and talk about, let alone study reliably and validly.
Tyler Carpenter, 6 Marzo 2006
I'm not sure that many would argue your points regarding the limitations of an epistemology derived from those terms as you have done, Allan. The issue is not whether reality is as complex as you describe, but how do we chose constructs that by their very definition violate the integrity of the whole, but allow for a more dynamic examination of their operation in the context of therapeutic relationships? Said a different way, I don't think that one needs to toss out the terms objective and subjective, so much as to study their relationship within the epistemology you suggest. Whatever terms you use to describe the component parts, the success of the design is going to rise or fall on your ability to establish meaningful construct validity and then demonstrate replicable results between the manipulated variables. Part of the problem with the EST stuff I've read is that it is such a weak approximation of the reality of the therapeutic relationship (let alone complex formulations of real psychopathology) that it is hard for results to establish much more than we already know or to say something more about a limited number of dimensions in a multi-dimensional phenomenon.
Hilde Rapp, 6 Marzo 2006
Dear Allan,
Thank you again for taking the trouble to point out that, as expressed so far in this discussion, my meta- model has been presented in a way that leaves too much room for misunderstanding.
Yes, of course there is no such thing as a monadic subjective mind- we understand ourselves and we think about ourselves through language- I am with Benjamin Lee Whorff and Lev Vigotsky on this, and significantly also with Bakhtin: our imagination is inappellably dialogic.
And of course there is no such thing as an objective, or natural, science in which our observations are free from subjective as well as collective distortions by way of observer effects, perceptual set effects and context effects, let alone expectancy, interpretation, ‘ideological’ bias etc ( the first thing I learnt in my course on measurement, decision and control, looking at the psychology of perception and cognition, when measuring reaction times to stimuli of a certain luminance!).
My meta- framework is purely heuristic- it does not aim to set out an epistemic position: it merely takes account of the fact that there are bodies of ‘knowledge’ ‘out there’ which subscribe to certain epistemic assumptions, such as ‘direct access to the contents of our minds’, ‘unmediated’ experience ( for instance within Buddhist inspired mindfulness based cognitive therapies – we can’t actually prove that our sense of having a direct experience of unity is not an illusion related to a particular biochemical- bio-physical brain state…), or a position which prefers to remain entirely silent about anything we cannot directly observe and measure as in radical behaviourism whether informed by Occam’s razor or modesty, making no positive assertion that what we can’t see doesn’t exist… .
My meta-framework is an ordering device, it aims to map what is out there for a particular purpose relevant to your current therapeutic task: if you want to find reports, studies, information, theories etc relevant to certain aspects of your work, - I invite you to look through the lens of this or that quadrant and you may find relevant material.
Each person who chooses to use this framework is invited to look at their client work from all four aspects, even if, ostensibly, the ‘problem’ which necessitates some research or enquiry seems to be clearly located in one quadrant: the clients social skills are appalling, say, and we are looking at this in relation to developmental ‘deficits’ ie from a Q3 biological basis of behaviour and social developmental patterns of attachment, affect regulation, failures in ‘mentalisation’ and schema based relationship formation perspective …
It may help to also look, even if only in passing, at what beliefs, attitudes, phantasies and existential torments might inhabit the client’s mind- and indeed our own (Q1), and to do so with an eye on philosophies past and present, be that the Buddha or Descartes, psychologies past and present be that William James , Sigmund Freud, Lacan, Perls or Ellis, Wachtel, Carere and Zuckoff etc… as it were…
Something may be learnt from understanding more about how this mind is embedded in a society in which certain coercive processes may have shaped the client’s parents to push the client into particular roles, to adopt a certain way of symbolizing his or her experience which did, it would seem, do violence to their own meaning system, and where dialogical forms …( Q2) were replaced by ‘acting out’ or ‘enacting’ conflicts behaviourally, ( Q3) The studies which might ‘show up’ in Q3 may well address very similar issues, but usually from within a different tradition and using a different vocabulary for instance in the field of substance misuse or domestic violence and there may not be much cross referencing between the work of Carlo Di Clemente and Ronnie Laing even though they both accurately diagnose what is wrong and prescribe what may help. (There are more psychotherapies, Horatio, than you have ever dreamt of…)
The study of institutions and their effect on what we consider normal and desirable, the extent to which power structures are designed to include or exclude and how this impacts on our clients experience and reality will usually make a difference to whether we see certain behaviours as defenses against oppression, racism, homophobia or whatever, or as the paranoid phantasies of someone on the verge of a psychotic breakdown, or indeed, a mixture of both! (Q4) or a drug induced temporary state ( Q3) . DSM IV etc may effectively screen for general life conditions, an understanding of the health care system will help us locate appropriate pathways to care, health policy will address the politics of how to tackle inequalities etc, all of which connects with structure grams and statistics and sociological enquiry into public health related factors ( Q4) but we need to look to Q2 for theory driven critiques of how we do describe and research such issues informed by people such as Weber, Foucault or Habermas etc… and to rule out biochemical imbalances (Q3).
My personal experience has been that I have found extremely useful pointers to information I needed to better understand my clients in studies whose underlying assumptions I do not share at all, and whose methodology I found in some way questionable. A ‘re-analysis’, re-ordering- rethinking of ‘data’ presented in certain studies would on occasion point me to an interpretation of findings quite different from those elaborated by the authors in their discussion. This would usually put me on the trail of looking for other work where, with luck, I might find studies or inquiries that were closer to my own preferences regarding assumptions and favoured methodologies, providing me with some evidential basis for my intuitive take on the client’s issues – that is provided I also took full account of any countervailing evidence that would cast doubt on my currently favoured hypothesis…
The four quadrants are really pointers to living webs of ever changing knowledge, skill, information, hypotheses, data, assumptions, hypotheses, etc that have their centre of gravity on one tradition rather than another, quote a certain body of literature that has a certain coherence, rather than another.
I ask that integrative therapists should endeavour to consider- not cover- as that would be impossible- all four bases. Most integrative therapists will have a preferred home base which brings with it in depth familiarity with a particular discipline, domain, universe of discourse, set of models and practices etc. All I ask is integrative therapist be aware that this is so, and to respectfully look next door with a degree of curiosity, and on occasion in genuine search of help ‘from outside’.
The meta- framework differs from many existing bio-psycho-social models in that it does not in itself offer a particular blend of psychological biological, socio-cultural bodies of knowledge and practice that could be set down in a textbook. It is a tool for acquiring such knowledge ( if a student) or for applying such knowledge ( for seasoned practitioners) .
Anyone who uses it would of course use it to organize their own core menu of questions asked about decision making procedures which take into account philosophical inquiry and scientific methodology and that operate upon a core curriculum of findings about human psychology and development through the life span, dialogical processes explored through ethics, aesthetics and anthropology, and an understanding of the workings of living systems comprised of institutions, organisations and the natural world…
Once we have acquired and organized our own bases of findings, understandings and practices we ally for new journeys into unknown territory. What we may ‘know’ today’ will always need to be live, constructed out of different facets, useful for a particular line of inquiry relevant to a particular client, but there will be some family resemblance between what integration we achieve today regarding client x and what we put together yesterday regarding client y and what we may construct tomorrow regarding client z. There will be a family resemblance between what we do over time, we all have a signature tune, but if we are truly integrative we are forever composing new pieces and forever innovating, yet without loosing our personal and professional shape. We will be subject to the usual pressures of competing personal and professional responsibilities, bad hair days and other factors likely to impair our judgment- but the aspiration to do a reasonable job is always there…
The purpose of the meta- framework is to help us to research and inquire in an integrative fashion. What we need to know in order to practice in an informed way, responsibly ,effectively, efficiently, and above all wisely.
The onus is on each of us to examine whatever we find with careful regard to the underlying assumptions, both the assumptions of the authors whose work we draw on, and our own. This means being open about the inevitable fact that each of us has preferences, a default standpoint and certain historic allegiances.
Conflict is healthy as long as it is not adversarial and ad hominem ( feminam) , but rather it is the motor which drives forward a form of collaborative enquiry where we openly compete with one another to find the clearest questions and the most well formulated answers to issues of common concern.
We are openly and honestly advocating for our own synthesis, integration, analysis, truthfulness, accuracy of observation, ethical practice .
This is called dialogue and it keeps the inquiry open to the future, ie, dynamic and with a living growing edge…
I am spelling many these issues out in more detail in a book which is ninety percent complete – you are welcome to have a preview – and I will illustrate this way of working at the Florence conference with a practical case example
Allan Zuckoff, 6 Marzo 2006
Hilde,
Do you remember the rubric quoted by Foucault from Borges that I used previously as an illustration? I had the same sense of disorientation when I read your line,
<<psychologies past and present be that William James , Sigmund Freud, Lacan, Perls or Ellis, Wachtel, Carere and Zuckoff etc… as it were…>>
Thank goodness for that “as it were”—otherwise I might have been permanently shifted into some unfathomable episteme within which such a sentence could be deemed comprehensible.
With this notable exception, I believe I finally understand the nature and purpose your meta-framework, and all I can say is: it’s a fascinating model. Thank you for taking the time and effort to lay it out so clearly that even I can grasp it. I look forward to paying for and enjoying your book when it becomes available.
Paolo Franchini, 6 Marzo 2006
Aderendo alla sollecitazione di presentare in anticipo il contributo che intendiamo proporre al Congresso ed entrando solo ora in lista in un dibattito complesso che si propone da anni tra persone preparate, desidero condividere l'esperienza che come Associazione - APPPER - stiamo facendo sul piano del confronto clinico, trasversale ai modelli e agli indirizzi, da 10 anni tra colleghi di diversa formazione in una logica di "supervisione alla pari" con una partecipazione non certo proporzionata al numero degli psicoterapeuti emiliani tutti regolarmente invitati
Costruire e concepire la Psicoterapia all’interno di una visione complessa e unitaria della Psicologia clinica.
Scrive Tullio Carere:
<<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. Un’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 com’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. (…)
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.>>
Scrive Paolo Migone:
<<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>>.
Scrive Daniela Maggioni:
<<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
(…)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);
- 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.>>
Rispetto quanto ho riportato, che ritengo aspetti tutti rilevanti e da “integrare”, desidero dare testimonianza della esperienza dell’APPPER ( Associazione per la Professione di Psicologo clinico e Psicoterapeuta - Emilia Romagna)
L’APPPER, è nata 10 anni fa dalla sezione emiliana della Società Italiana di Psicologia Clinica di cui sono stato il Vice presidente Nazionale, per eludere gli aspetti burocratici di un’associazione nazionale e potersi concentrare sulla dimensione clinica del lavoro dello psicologo e dello psicoterapeuta.
Alcuni amici ed io ne parlammo diffusamente con Pier Francesco Galli e nacque così l’idea di fondare presso l’Istituzione “G.F. Minguzzi” di Bologna l' APPPER "Conferenza Permanente di Psicoterapia Clinica".
Il richiamo a Gian Franco Minguzzi era riferirsi ad una delle intelligenze più vivaci del mondo accademico della Psicologia e della Psicoterapia, che aveva guardato con occhio critico e disincantato l’enfasi delle appartenenze ai dogmi di Scuola e d’indirizzo.
La Persona del terapeuta diviene per noi soggetto d’integrazione nella logica dell’assimilazione e dell’accomodamento, di cui si è qui ripetutamente scritto.
Iniziammo i nostri lavori strutturati in Cicli di seminari attorno a centri d’interesse che sono cambiati anno per anno secondo problematiche maturate nel corso dei lavori a partire dal tema iniziale intitolato “Tecniche e soggettività.La persona dello psicoterapeuta”, seguito dal ” Mestiere dello Psicoterapeuta”.
Invitammo come relatori figure significative della Psicoterapia Italiana, quali Diego Napoletani,Giampaolo Lai, Roberto Speziale Bagliacca, Pier Francesco Galli e Luigi Pagliarani , ai quali fu chiesto di svestirsi di una certa “ufficialità di ruolo” e dare testimonianza della loro concreta esperienza nel contatto con i pazienti di ciò che dopo un lungo cammino ritenevano peculiare del “Mestiere dello psicoterapeuta
E’ stata una ricerca sul piano clinico ed esperienziale che voleva individuare i “fattori comuni” essenziali nel rendere efficace l’atto clinico, se è vero che terapeuti, pur appartenenti a indirizzi diversi ottengono, risultati positivi.
Con una sintesi, che ne penalizza la profondità, i fattori emersi essenziali nei nostri lavori possono essere così sintetizzati:
Non si può in nessun caso eludere la relazione “terapeuta-paziente”.
- La tecnica svolge un ruolo essenziale (ma non sufficiente) nella cura
- Il fattore aspecifico della “Persona del terapeuta” svolge un ruolo determinante nella cura.
- Le ricerche statunitensi e lo sviluppo della psicoterapia in ambito psicologico soprattutto in direzione comportamentale-cognitivo negli Stati Uniti hanno fortemente risentito della restrizione della psicoanalisi ai medici durata fino al 1989.
- Più il caso è complesso e maggiore è l’incidenza della “Persona” del terapeuta
- La Tecnica, intesa come atteggiamento neutrale avvicina di molto l’approccio psicoanalitico classico (modello passivo-interpretativo) a quello comportamentale-cognitivo (modello istruttivo-pratico) che appaiono adatti a personalità nevrotiche, ma non a casi complessi con nucleo psicotico.
- Le conoscenze in ambito psicodinamico, cognitivo-comportamentale, umanistico e sistemico-gruppale con particolare riferimento alle recenti Teorie delle relazioni oggettuali, del Sè e dell’Attaccamento sono conoscenze essenziali della Psicologia clinica e nella formazione del terapeuta, che dovrà privilegiare un ambito d’intervento tra quelli possibili.
Da quanto sopra si individuano già oggi come imprescindibili aspetti essenziali della Psicologia clinicasecondo una concezione multifattoriale dei processi psichici e comportamentali, che fin da ora si evince dai diversi studi della Psicologia clinica contemporanea, quali:
- La centralità della formazione della Persona del terapeuta.
- La conoscenza delle dinamiche transferali e controtransferali .
- Un lavoro approfondito sull’empatia.
- La conoscenza della psicopatologia con riferimento alla stessa classificazione del DSM IV°.
- Lo studio delle neuroscienze
- Lo studio delle tecniche cognitivo-comportamentali
- Lo studio del movimento psicoanalitico e psicodinamico
- Lo studio dell'approccio umanistico
- Lo studio dell'approccio sistemico e gruppale
Occorre uno sforzo nel concepire come parti di un tutto gli studi e gli sviluppi degli Indirizzi e dei Modelli ed in Psicoterapia, superando l’assunto che una teoria e una corrente di pensiero possano esaurire la complessità delle dinamiche psichiche e dei comportamenti sulle quali da poco più di un secolo si sta lavorando.
E’ il riduzionismo ingenuo, quanto assurdo, che va combattuto per ricondurre ad un insieme complesso che è la Psicologia clinica
In quest’ottica non si fa dell’eclettismo come non è eclettica la Fisica che si compone di una complessità di teorie non sempre tra di loro convergenti.
Si tratta di superare l’assunto ingenuo ed ideologico che un pensatore per quanto geniale e una corrente di pensiero esauriscano la ricchezza e la complessità della Psicologia Clinica delle cui conoscenze siamo solo agli inizi.
Se, invece, è una questione di visibilità o di potere…… ALLORA PARLIAMO D’ALTRO e lo denunciamo.
Per questo rimando alle puntuali e acute osservazioni di Daniela Maggioni.
Tullio Carere, 6 Marzo 2006
Allan, Hilde, Tyler, Zoltan
Hundreds or thousands of things happen in a session, all of which are idiosyncratically interpreted and responded to by both patient and therapist. Real therapy, as any genuine inter-subjective exchange, and as is clear to common sense and to Stern's Boston research group, is basically floppy (unpredictable), whatever the therapist's theoretic allegiance. Of course, from this intricacy one can extract all sorts of testable hypotheses, put them to test, produce procedures supported by those tests, and apply such procedures to the intricacy in the sincere conviction that this will improve the efficacy of real therapy. This is the scientific approach to psychotherapy, and I have nothing to object to those (therapists or patients) who feel more at ease in this sort of relational environment.
I, among others, feel more at ease in the common sense approach to psychotherapy, corresponding to the assimilative-accommodative integration. In this approach the therapists assimilate whatever theory or technique suits their taste or temperament, and bracket out as much as they can all their theories in order to accommodate as much as possible moment by moment the demands of the process. In the common sense approach protocol driven procedures are sheer non sense; but the common sense therapist feels compelled to produce objective material (mainly post session questionnaires and written notes by both patient and therapist), whenever needed, to monitor and document the process and to correlate process and outcome.
Ps. Tyler, thank you for saying <<I suspect that the phenomenon that Tullio is referring to is more subtle than the research solution you are proposing, Allan", and "one of the flaws of analytic research was that in order to examine concepts with real construct validity, one was forced to stay close to the surface>>
Tyler Carpenter, 7 Marzo 2006
Not sure I see the two positions as that dichotomous, Tullio. I think it may be the hypothesized mutual exclusivity and reducing the dialectic to anchor points that kills the discussion and the science. I think it fair to say that I can easily understand what I do in your framework. However, much research such as you describe is both the source of information on which I might base a medication referral or is the basis of a treatment protocol or ideology that my client is compelled to work with and which I can integrate if I broaden my understanding. Said a different way, I can practice as you say you do, but would lose much synergy for my patients if I neglected the contextualizing milieu or access to mood and thought modulators. Sometimes what I do is work with what others are doing or calling something and help my patient process the material therapeutically. In this respect perhaps I am more Taoist than Confucianist in my therapeutic sensibilities and pragmatism.
Allan Zuckoff, 7 Marzo 2006
Tyler,
I agree that there are subtleties that would be difficult if not impossible to capture in controlled research. Hilde’s post suggests that there may nonetheless be ways of capturing at least some of the variance via traditional research methods. And this is precisely where systematic qualitative research may capture even more.
A method I have used (in brief): record a therapy session of interest, break the tape into smaller parts, then invite the client to be interviewed about the experience of the session; offer instructions, play a tape segment, ask the client to describe his/her experience in the moment. Record the interview and have it transcribed, so you have the session segments and the interview segments linked. Do this with multiple clients, then use a disciplined methodology to first analyze each of the subjects’ experiences individually, then synthesize a general structure of the experience. This general structure is potentially replicable (or falsifiable), both through obtaining analyses of the same data by other researchers, and through repeating the analysis with data from other sessions/ other clients.
What matters most, I think, is not the specific method we use; it is our willingness to subject our intuitions and fondly held beliefs to a test in which they can be shown to be wrong. It is simply too easy, otherwise, to believe what we wish to be true, because we wish it so.
Tyler Carpenter, 7 Marzo 2006
Fascinating methodology, Allan, and I agree that Hilde's framework has much to offer.
For me these days it is the non-verbal emotional resonances and dissonances (e.g., vocal tone, facial expression, posture, verbal-nonverbal discordances, etc.) that I find both crucial to effective work and fascinating to process. When I reviewed the extant models of brief therapy at a Mass General Hospital seminars about 12 years ago I found that they were quite limited in applicability to severely disturbed populations (except for Leopold Bellack's model which was not covered and which I learned in a seminar with Bellack in the early 70s). I later saw Si Budman present on his character focused model (about 20 sessions I think). When adapting to working in prison I found that not only did I need to become aware of multiple comorbidities in diagnostic formulations, the nature of the "average expectable environment", the adjunctive use of medications, but broaden my conception of what Martha Stark refers to as the principal modes of therapeutic action, e.g., interpretation, experience, and relationship. In such interpretation, re-education, support, exploration, behavior, modulation of drive/affects, etc., take on fine nuances and it is the sound and fury that signify what is important to attend to, as well as what it is important to interpret and how to frame it.I absolutely agree with you about the importance of submitting everything to careful scrutiny. I couldn't have unpacked some of the concepts if I didn't do so. If I wasn't up to my neck in clinical work I could look closer at the process than current time and resources allow.
Tullio Carere, 8 Marzo 2006
As the Florence Conference approaches, it is time to draw up a first balance. The pre-conference discussion has taken place so far parallely on this listserv and on the Italian SEPI-list. On the latter Giovanni Liotti made a lucid point. Psychotherapy integration, he said, happens only on the ground of empirical research. On this ground psychotherapy is on its way of becoming a normal science, like biology or medicine. But the field is split: on the other side of the split there are those who refuse this integration. There is no other integration happening on that side, though: on the side of science integration is in progress, on the other side one finds only differentiation into myriads of school, group, or individual theories.
At this point of the debate I think that Giovanni is right. On the side of those unwilling to accept empirical science as the foundation of psychotherapy, the field is fragmented or pulverized by the joint effect of assimilative integration and eclecticism. As I pointed out earlier, assimilative integration is inevitable, inasmuch as we all go on assimilating pieces of other theories into our home theory through our all professional life. This paradoxical process is integrative at the individual level, but disintegrative at the field level. (As George remarked, an alternative to assimilative integration is eclecticism, which is disintegrative at both individual and field levels). The joint effect of assimilative integration and eclecticism is that there are almost as many psychotherapeutic theories as there are therapists in the room.
The differentiation of the field happening on the non-empirical side of the split would not be a trouble, were it balanced by the presence of a common ground, where common needs and goals were matched by common factors and strategies, and therapists could communicate among them on the ground of a shared common sense. On the ground of common sense, therapists could bracket out their pet theories and be able to dialogue with colleagues of different persuasions, and thanks to this dialogical space could change their minds and accommodate elements of different perspectives incompatible with their frame of mind. The integration would then be really assimilative-accommodative, not just assimilative with as little accommodation as possible.
Common sense, in which sound intuition and reason are balanced, is common to every human being, i.e. is available to anybody willing to conquer it; but on the other hand it is very uncommon, inasmuch as in order to conquer it one has to submit to a hard and permanent discipline like phenomenological epoché, Bion's freedom from memory and desire, or Gemma Corradi Fiumara's philosophy of listening. All these disciplines require the suspension of all preconceptions and expectations, which is experienced by the ego as a psychological catastrophe. As a consequence, none of these disciplines is very popular, almost no therapist puts one of them at the core of their dialogical approach and clinical practice. As common sense remains most uncommon and unpopular, common ground among therapists remains the bizarre utopia of 'common grounders', and the only integration really happening on the real ground is the one grounded on empirical research.
George Stricker, 9 Marzo 2006
How about an integration that does not occur on one or the other side of the divide, but between the two poles, representing a real seeking of a synthesis?
Tullio Carere, 9 Marzo 2006
George,
in a dialectical perspective no real synthesis is possible between a strong thesis and a very weak antithesis. The antithesis must grow, for a synthesis to be possible. The antithesis, to me, would be a full-fledged assimilative-accommodative integration. But how many would agree? Not many, I guess.
George Stricker, 9 Marzo 2006
A full-fledged assimilative-accommodative integration would be my preference for an antithesis (and I agree that a strong one does not exist and is needed for a synthesis to occur). However, it is not the only option, and any one that might provide an antithesis would start the process off, and might even be the impetus for further development of antitheses.
Tullio Carere, 10 Marzo 2006
George,
as a full-fledged assimilative-accommodative integration is the preference of both of us for an antithesis to empirically supported psychotherapy, and as we also agree that a strong one does not yet exist but is needed for a synthesis to occur, could we elaborate a little more on it, just to make it a little stronger?
Firstly, the assimilative side is precious inasmuch as it lets us tailor our theory on our tastes and preferences. My theory is an idiosyncratic summa of my history, personality and choices, nothing to do with manuals. I am free to choose the theories that best suit me, as the patient is free to choose the therapist that best suits him or her. In this perspective, the crucial therapeutic factor is the person of the therapist, not a technician who administers protocol-driven techniques. "As many theories as there are therapists in the room" is no longer a mark of weakness, but a sign of freedom and pluralism.
Secondly, the accommodative side makes me bracket out my theory all the time in order to get tuned with the demands of the process. It is the reciprocal of the request I make to my patient to suspend his or her convictions to have our dialogue progress. It means that the focus of therapy is dialogue, not a disorder to diagnose and treat by means of empirically supported procedures. Genuine dialogue happens when and to the extent that both interlocutors let go of their respective convictions -- personal, ideological, metaphysical, theoretical, whatever -- and rely on nothing else than common sense.
In sum, assimilative-accommodative integration means that the focus of therapy is on interpersonal relationship and dialogue, not on scientific proceedings (though science has some room in it, especially in the form of the local scientist -- as of course in ESP there is some room for dialogue, but the focus is not there). I see assimilative-accomodative therapy and ESP as two different and incompatible things, one basically dialogical and heuristic, the other basically epistemological and protocol driven. The great divide reflects a real difference. It seems to me that before trying to make any synthesis between the two, it would be necessary to firmly establish the autonomy and independence of one another as two distinct disciplines. It is too soon for conciliation. Reciprocal acknowledgment and respect come first, in my view..
George Stricker, 10 Marzo 2006
Tullio,
I hope that it is not too soon for reconciliation, and perhaps the key is in your statements about ESPs. Generally, I agree with you, and feel that they are limited and limiting. However, I do not equate science or scientific contribution with ESPs. There are many other epistemological approaches to research, such as practice networks, effectiveness research, systematic case studies and N=1 approaches, and so on. If we expand our notion of research, we also can expand the possibilities of a synthesis (or at least I hope so).
Zoltan Gross, 10 Marzo 2006
Dear Tullio and George, Underlying your theories of both dialectics and basing psychotherapy on empirical science is the assumption that we are all examining the same "elephant" of psychotherapy and that we are all speaking to one another in the same "language" about our discoveries of the parts of the elephant we are exploring. I don't believe there is a single psychotherapy, which is the implicit assumption of the discussion. While it might be true that a cognitive behaviorist and an analytic therapist might both be successful in alleviating the anxiety of the person with whom they are working, I seriously doubt that personalities of the persons being treated wind up in the same place. The cognitive behaviorist's work has little to do with character structure. On the other hand, analytic work, relational or transferential, does alter the emotional structures of the people with whom they work. I believe there are different psychotherapies serving different personal goals. The Dodo bird awards are only given to the experiential end results of therapeutic work. Prizes are not awarded for personality change. Which brings me to my second point, so far empirical research does not have a common language with psychotherapy about the definition of personality, emotion, self, cognition, or consciousness. The words used by both systems are the same but they speak different languages. The words don't mean the same things in the different systems. As a matter of fact, in a recent article by the president of APS declares that research in personality and psychotherapy are so different that they will never meet. He ended his comments expressing his belief that this was the way it should be. Unfortunately, not only are we blind in our examination of the elephant of psychotherapy, but when we communicate our findings we don't speak the same language. While assimilative integration is an agreeable hope, I believe it is very unlikely until we get past the pre-paradigmatic stage of knowing that George recognized
George Stricker, 10 Marzo 2006
I think that Zoltan's metaphor about the elephant is well taken, and agree that the issue of therapeutic goals is often overlooked when comparing therapeutic outcomes. It makes as much sense to speak of "psychotherapy" as it does to speak of "medication" or "surgery."
Tullio Carere, 11 Marzo 2006
George, Zoltan,
I see a variety of animals, not just elephants. But in this variety I believe to perceive a sort of order. Some animals are elephant-like, or strive to look like elephants, the most powerful animals of all.
Others are cat-like, much less powerful but proud of their cat-ness, and not willing at all to look like elephants. Then there are of course all sorts of intermediate forms. Sure enough, they are all mammals. But for the time being to concentrate on the general mammalian structure risks to make us lose sight of the substantial difference of at least two main species, as I see them: the species of
those who are fascinated by science (all sort of scientific research, not just RCT), and believe that science has the last word in deciding what is valid and what is not in their practice; and the species of those who have a moderate interest in science, but are much more interested in interpersonal interaction governed by genuine dialogue (which requires the sacrifice of all preconceptions and myths, the myth of science included). It seems to me that cats are an endangered species today, at risk of being crushed by the elephants' stampede. We should protect poor cats.
Tyler Carpenter, 11 Marzo 2006
Perhaps a first step for such an integration to begin to occur, George and Tullio, is to set up some tentative conditions and parameters: Many discussions on such topics are so wide ranging that although they discuss the broad issues, there is much time spent on discussing the fine points of mutually accepted dynamics, e.g., the acceptance of a need for research & clinical thinking/experience, the idiographic and the nomothetic. By finding a limited consensus on a topic and some sufficiently representative participants to discuss it, you have both a goal to be refined and a constituency to address the question.
Tyler Carpenter, 11 Marzo 2006
Zoltan Gross wrote :
<<Dear Tullio and George, Underlying your theories of both dialectics and basing psychotherapy on empirical science is the assumption that we are all examining the same "elephant" of psychotherapy and that we are all speaking to one another in the same "language" about our discoveries of the parts of the elephant we are exploring. I don't believe there is a single psychotherapy, which is the implicit assumption of the discussion. While it might be true that a cognitive behaviorist and an analytic therapist might both be successful in alleviating the anxiety of the person with whom they are working, I seriously doubt that personalities of the persons being treated wind up in the same place. The cognitive behaviorist's work has little to do with character structure. On the other hand, analytic work, relational or transferential, does alter the emotional structures of the people with whom they work. I believe there are different psychotherapies serving different personal goals. The Dodo bird awards are only given to the experiential end results of therapeutic work>>
I suspect the issue is not so much whether we are using the same language, Zoltan, because it seems as though we are. The language is English. However, we do at times move fluidly between professional vocabularies and our understanding of them and this tendency to do so makes the discussion both more personal and in ways perhaps more undermining of an attempt to develop a common assimilative- accomodative framework that both accrues certain agreed upon and shared structures (nomothetic) and terms, while also allowing for individual divergencies (idiographic) in structures and meaning. There may be no single psychotherapy in the narrowly defined sense, but there are ample examples of common practices or ways of being therapeutic that are clearly supported by empirical literature or easily discerned by translating terms and structures and processes from one framework to another. This last point leads to my next one:
I think to draw the distinctions you do about cognitive vs. analytic approaches to anxiety and character is to make the approaches more separate than they actually are in practice and to talk about how a process may be described rather than how it may in fact occur in terms of both frameworks. To take the example of addressing anxiety using both frameworks, there is nothing that would suggest to me that either framework neglects the role of personality and its relationship to anxiety. And broadly construed there is nothing that suggests to me intervening cognitively has any less or more to do with character and symptom in one framework as opposed to the other. Both disciplines utilize interventions of a cognitive nature aimed at changing the relationship of understanding of symptom to personality context and while the vocabularies and timing may differ, with an understandable difference (perhaps minimal) difference in change in the individuals involved, this is as likely to be something found within a group of analysts or a group of cognitive behaviorists talking about how they do what they do.
I think it was Roy Schafer who attempted to deal with a similar cacophony and chaos in the analytic community by writing a book on changing the language used to describe therapeutic change(perhaps more accurately professional terminology) that focused on what is actually done rather than spending time sorting out specialized terms and constructs that become a source of contention among groups trying to discuss (at least on one level) what they are trying to do in their work. Said a different way, both analysis and cognitive therapies agree that distortions in perception are anomalies in ideal adaptations to the world and focus on these anomalies is central to the process of restoring a relative functional adjustment with respect to cognitive-affective and interpersonal function. One group calls such anomalies cognitive distortions and the other calls them defenses. Useful dialogue may proceed from laying out and discussing how these terms differ in assumptions they imply as well as in how their role may be addressed both in theory and practice of restoring function in patients. When this happens it becomes quite clear that there are often differences within professional groups that are as profound as between groups with respect to how the individual practitioner makes use of the structures to address the problems at hand in the treatment.
Tyler Carpenter, 11 Marzo 2006
However, Tullio, such a distinction seems to be as much about how you choose to use the terms and bound the discussion (see Lewis Carroll's quotation from "Through the Looking-Glass." on how and what words mean and are chosen to mean), as it does about the data and processes involved. The results of the research that undergirds ESPs is as likely to be heuristic and provisional and reflective of common sense, and hence to be assimilated and accomodated by the local-scientist, as are the results of a common sense focus on the person of the therapist in the therapeutic dialectic For example, see how Ebbinghaus' personal observation of his memory has stood the test of time. We are talking in large part about preferences in the qualitative characteristics of methodology and not necessarily about what each method produces for assimilation and accomodation by whoever and whatever we choose to call the common model (which I submit is not a bad way to describe it and avoids the superfluities and pitfalls of double-think - call one thing by another set of terms). To be a little subversive, I suspect that if we were not to discuss where we got the data we are submitting to the process, it would be damned difficult to determine whether it was from ESP research or self-other clinical observation. Perhaps that is a better way to proceed and thus dispense with the question of determining first whether something had a previously determined authenticity and then second whether and how it could be assimilated and accomodated in a larger and agreed upon framework.
Tullio Carere, 11 Marzo 2006
Tyler, I am not sure that I understand what you say. What I say is that there are two basic attitudes among therapists: one is theory-centered, the other is dialogue-centered. The theory-centered depends on empirical testing, the dialogue-centered depends on the training of the capacity of genuine listening. The first discipline is much more popular these days. I have tried hard, years long, to reconcile these two attitudes (the first SEPI-Italy conference, 2002, was the highest point of my efforts in this direction). Now I have given up, I don't think any longer that these two attitudes can be reconciled. Not in this phase of development of psychotherapy. Not until the dialogue-centered becomes a strong enough antithesis to the theory-centered.
Tyler Carpenter, 11 Marzo 2006
I would both make myself clearer and amend your position as follows, Tullio: Two of the basic attitudes that therapists consider are theory centered and dialogue-centered. Theory and dialogue can both be empirically tested (formally as in a "scientific" study) or individually tested as in careful and thoughtful observation of dialogue. Both approaches are characterised by careful listening and attention to the variables involved. The zeitgeist is predominated by the former methodology.
Sometimes people resist being put in a box and having data systematically excluded from discussion and integration. I couldn't survive and thrive in prison if I engaged in drawing overly exclusive distinctions. That, and not punitive ideology and maladjusted personalities, are the primary reasons psychology and psychiatry haven't historically flourished in these environments. Sorry I can't be in Florence. I hope we get to meet in person some day. If you enjoy a thoughtful beer (not just the discussion accompanying the drinking, but the way the beer is crafted), I suspect you'd enjoy sharing one of my homebrewed beers. "St. Feullion's", the Belgian Tripel I just finished is great! The development of psychotherapy, by history and nature, has always been non-linear and proceeded on multiple fronts.
Tullio Carere, 11 Marzo 2006
Thank you Tyler for clarity and amendment. I understand that people don't like being put in a box. Yet concepts are boxes, aren't they? Can we do without concepts if we want to reason? But let us try to use our boxes judiciously. Both the theory-centered and the dialogue-centered therapist have their own theories, but the difference is that the former is highly motivated to apply rigorously their theory (from which their professional identity usually depends: I am a "Gestalt therapist", or a "Kleinian psychoanalyst" inasmuch as I am true to the theory of my school or group): whereas the latter is much more motivated to bracket out their theory (from which their identity depends much less) for accommodating whatever in the relationship with their patients resists being assimilated by them.
Even if the theory-centered therapist is not a school therapist, but a conscientious therapist willing to apply empirically supported theories and techniques, she knows that she cannot empirically test
her theory inside the session: she has just to hand her material over to professional researchers, who will give her in exchange the last empirically supported theories or techniques to apply. Quite another story for the dialogue-centered therapist: she is a researcher and a local scientist in her own right, she uses moment by moment the feed-backs she gets in the relationship for adjusting her theory.
Finally, both the theory-centered and the dialogue-centered therapist are interested in the external validation of their work. But the methods are quite different, whether or not one chooses to call them "empirical". The theory must be transformed in a protocol and studied in an experimental setting. The dialogical therapist must produce objective material, like recordings, post session questionnaires or written notes by both patient and therapist to document their work. We have nothing to gain, I believe, if we mist and blur these basic differences for fear that someone feels being put in a box.
George Stricker, 11 Marzo 2006
I'm not sure that I see the basic distinction as between the theory-centered and the dialogue-centered therapies. As you quite appropriately note, both need external validation. The question is whether we look to laboratory science or local science for that validation, and my point is that the operative word should be "and" rather than "or." For the theory-centered therapist to reject data from the local clinical setting is silly; for the dialogue-centered therapist to reject data from more tightly controlled studies is equally silly, in my mind. Each has something to contribute to knowledge, and each has weaknesses that limit what they can teach us. If we can learn what they have to offer while keeping in mind where they fall short, we may be on the road to a more sound knowledge base.
Tyler Carpenter, 11 Marzo 2006
You're welcome, Tullio.
For me, box in this context is a rhetorical device. Concept is neutral language/vocabulary. If I think outside the box or come out of the box (both of which metaphors are good descriptors of my behavior that are highly congruent with how others would describe me and how I behave) those describe how I respond to being restricted in my thought and behavior. I see your point about identity or self. This concept comes in various kinds and sizes and neither implies narrowness or excessive (or any) reliance on empirical proof. In fact in the narrow sense excessive boundedness by parochial or personal definitions might be seen by some as on a continuum or a dimension with a more open and inclusive sense of who one is .So as we play with the concepts things don't appear to be so exclusive and the opportunities for dialogue and understanding and integration can expand.
Whether one practices in one setting or another, the issue remains methodological and there is no corresponding theoretical mandate to surrender control of ones evaluative processes, though others may choose to see us differently (and there Einstein's thinking may have much to offer our discipline about the nature of relativity). As for external validation, different folks require different kinds. In the prison, most everyone demands that the individual who talks the talk walks the walk. Whether you get there by introspection or journal reading, results everyone can see and live with is the only real measuring stick accepted by all, whatever they call themselves and whatever role they fill. I think the concept of fuzzy boundaries is not only a pragmatic approach, but a part of the conceptual tools of modern mathematicians, but then I'm way over my head when it comes to that particular application.
Tullio Carere, 12 Marzo 2006
It obviously would be silly to reject useful data, wherever they come from. The question is: are laboratory data really useful to the dialogic therapist? The low-to-null external validity (applicability to therapies in the natural context) of laboratory data has been pointed up many times, and can be easily explained by the fact that laboratory data refer to protocol driven treatments, whereas in the natural context therapists are inclined not to work in the protocol mode, unless they are inexpert, insecure, or bound by time-limited or otherwise altered settings, because laboratory treatments bear only a pale resemblance to real treatments. Peterfreund introduced the useful distinction between heuristic and stereotyped therapists. Heuristic is akin to dialogic, stereotyped is the therapist who uses standard, manualized procedures. Laboratory data are perfect for the stereotyped therapist, but I would hardly say the same for the heuristic or the dialogic. I, for one, don't remember having come across a single laboratory finding useful for my everyday work in more than three decades of professional (not academic) life.
George Stricker, 12 Marzo 2006
I'm not going to defend manualized laboratory work, as I am well aware of all the limitations. However, if we use more standard research to explore principles of change rather than the impact of specific interventions on artificial groups, there is much more that can be learned.
Tyler Carpenter, 12 Marzo 2006
Tullio, it's hard for me to imagine how a manual driven approach or a study of say a systematic desensitization or implosion therapy approach to dealing with a feared object couldn't be productively integrated into a dialogic approach. First, because there is more consistency between the application of Lab and real life applications (the goal of such approaches is just such a veridicality); and, secondly because a dialogically oriented therapist could tweak or adjust the application precisely because the feedback was so readily available either in the derivatives or manifest behavior (including non-verbal behavior).
Case in point (and understand I generally eschew labelling myself in any particular way): I was trained in EMDR and have read and listened to much on paradoxical therapy. Though I think in my therapeutic niche a complete integration of protocols for these approaches is not always possible or even desirable, I have no trouble incorporating the principles in my work (e.g., close attention to eye movements and nonverbal reactions when processing traumatic material, including character embedded transference; response to paradoxical suggestions in the context of ongoing therapeutic dialogue). In fact it is precisely the fact that I work this way that allows me the flexibility you say only belongs to the person who labels himself a dialogic therapist. It sounds to me like you are suggesting throwing out the entire set of results of empirical treatments, which themselves are only ostensibly controlled amalgams of the components we all use and pay attention to when we work. Said a different way, one might even characterize certain therapies, especially the research based ones, as hypertrophies of factors that are an element in all therapies.
Finally, if I remember my history correctly, the reason that manualized approaches were developed was not to substitute them for a more idiographic approach, but to control the relevant variance and compare the active ingredients in studies that were of ostensibly different therapies. In fact, the authors of the manuals (Hans Strupp, Lester Luborsky, Aaron Beck) used in research were generally analysts (Menninger or Topeka, and Washington School of Psychiatry?) by training and history that were putting the products their clinical training to the formally empirical test. In fact, for years they were the only type of psychologists that were given full and validated training sanctioned by the American Psychoanalytic Association. The manuals served the dual purpose of research protocols and training tools for their students. However, the best source for explaining this history is likely SEPI members Mo Parloff, Irene Elkin or Barry Wolfe (who used to head NIMH's Psychotherapy Research Branch) or the authors themselves who I believe are on the Board of Advisors for SEPI, right George?! Wasn't Peterfreund also an early researcher on sex offenders?
Finally, the question is not just is the hypothetical gap between researchers and dialogic clinicians, but between members of the supposedly same therapeutic schools of thought? Before there were psychotherapy wars between different schools there were conflicts between those who formed the separate schools (initially sects to be precise). A senior colleague once told me that Lacan once analysed someone who had been treated with ECT. Now if that isn't simultaneously dialogic and research driven, I don't know what is.
George Stricker, 12 Marzo 2006
For history, Tyler, every one you mentioned has been a SEPI member, at least, and in Barry's case, even is on the Steering Committee. My memory about the origin of manualized treatment is to ensure treatment fidelity - that is, that people who said they were investigating a brand of therapy really were doing it. Of course it then expanded into a prescription for future treatment, but that is another story.
Barry Wolfe, 12 Marzo 2006
Just to amplify George's remarks, the NIMH made a decision around 1976 that to study psychotherapy was to study the specific techniques of psychotherapy. The behaviorists had shown us with manuals developed in the early 1960's that therapy techniques could be operationalized and manualized. This decision came on the heels of two decades of NIMH-supported outcome research on so-called "traditional psychotherapy" and no one knew what that really meant. In order to insure treatment fidelity, as George says, and to increase the interpretability of the outcome data, the requirement was introduced that grant supported psychotherapies need to be manualized. Moreover, a manualized psychotherapy was viewed as the closest thing to a standardized medication which would then allow comparisons of research findings from both psychopharmacological and psychotherapy studies. The status of a given psychotherapy was based on how well it compared to a medication in reducing symptoms of specific disorders.
By the way, I vigorously fought this sea change in what was called "fundable psychotherapy research" because I knew it sounded the virtual death knell for psychotherapy process research. I lost!!
Tullio Carere, 12 Marzo 2006
Tyler,
I assimilate all sorts of behavioral and even pharmacological procedures into my psychodynamic home theory inasmuch as my focus is never on the procedure itself, but always on the metaprocedure, i.e. the way a therapeutic action is experienced by the patient here and now. In other words, my focus is always on the meaning of every therapeutic interaction in the actual context, never on the meaning the same (inter)action is given somewhere else, a lab, Freud's office, whatever. I pick up therapeutic suggestions in a completely heuristic way: "Someone reported that this procedure could help in cases similar to the one I am treating, let us see what happens if I try it here". As much as possible, I apply procedures that I have experienced on myself: beyond my analytic training, I have had many therapeutic experiences in different approaches (for instance, I too had an EMDR training in Philadelphia). But in every case I am guided by common sense, not by manuals, in the application of a procedure, and I am totally unimpressed by lab results: I use a procedure only if I have experienced it on myself or am persuaded by the description of somebody else who has employed it.
As an example, let me describe the way I integrate psychopharmacology in my approach. I am a psychiatrist, and have learnt to use psychotropic medicines in the years of my residency and working four years in a psychiatric hospital. When I left the hospital and started a career as a psychotherapist in private practice, thirty years ago, I never prescribed medicines, because the Zeitgeist of that time did not allow it. When I thought that a patient needed medicines, I referred her to a colleague. By and by I learnt that to integrate my work with that of the psychopharmacological colleague was more complicated than to integrate psychopharmacology myself. Now I quite often prescribe medicines, above all antidepressants, but only in the context of a psychotherapeutic relationship. I have no experience of these drugs on myself, but the experience of other colleagues and of many patients is persuasive enough of the usefulness of these medicines. Laboratory data should be more compelling in this case than in the case of psychotherapeutic procedures: in fact they are equally ambiguous and not compelling at all. According to some meta-analyses, the effect of antidepressants is not significantly different from that of active placebo. Dodo bird rules here too.
My personal opinion is that antidepressants do have a significant pharmacological action, although the placebo effect is very high. In any case, when I prescribe an antidepressant its specific action is never in the forefront in my mind, as with any other procedure. I can propose an antidepressant when the patient says that she feels too bad and believes that psychotherapy does not help enough. Like Hilde, I have my own heuristic mandala, a four-vertex model to orient myself in the therapeutic relationship. The horizontal axis connects the maternal-accepting and the paternal-confronting vertices. On this axis, the proposal of an antidepressant can be experienced as an empathic understanding of her suffering and an attempt at relieving it (maternal vertex), or as a confrontational intervention, something like "if you are not collaborative enough, I'll have to give you a medicine" (paternal vertex). My heuristic model helps me understand the patient's experience of the prescription (the metaprocedure), but then I put even my mandala aside in order to listen "without memory and desire". This is an example of my assimilative-accommodative approach, in which manual driven approaches have no place at all. I hope this helps our dialogue.
Tyler Carpenter, 12 Marzo 2006
Although I am not a psychiatrist, Tullio, I clearly work and assimilate techniques and refer to/consult with our psychiatrist in ways quite similar to you. We don't describe some of the ways we label what we do the same and in this we are congruent with much of the empirical literature that shows that whatever therapists call what they do, in many ways they are quite similar in their actions. Thank you for sharing your rationale in such detail. I find it very confirming of my approach as well, though we clearly differ in some of the ways we talk with others or discuss it.