Dibattito precongressuale
2° CONGRESSO S.E.P.I. ITALIA Firenze 24-26 Marzo 2006
Pagina 5
Hilde Rapp, 13 Marzo 2006
I just want to pick up on a few strands
1 - The relationship between goals and outcomes: for me what links these are values. Values help to shape the outlook which informs how we define goals, what means are acceptable and therefore what outcomes we seek to bring about.
2 - manualised therapies: as Barry reminds us, the original purpose of manualised therapies was to design a form of standardized ‘treatment’ that could be researched by methods favoured ( still) by governments who have to account to the public that they spend taxpayers money on treatments that are cost effective. The manuals become useful for training therapists and to test whether they are compliant – ie deliver the ‘treatment’ that had been found to be cost effective in scientific trials correctly, and thus effectively.
3 - character change: almost by definition, complex client ‘problems’ require complex therapeutic ‘solutions’. Complexity almost always goes hand in hand with uncertainty, unpredictability, making ‘ one problem- one solution’ scenarios unlikely. Therefore , manualised therapies which work in ‘one problem- one solution’ situations- for which they were designed, are unlikely to be able to deliver change.A more art and skill and tailor made intuitive approach is likely to be needed which will work with the resistances and conflicts that are part of the clients ‘mal’-adapted responses to ill understood challenges. The first therapeutic task may be to discover how the client understood, construed, interpreted a life challenges and what behvioural repertoires he/she had at their disposal to respond to this challenge at the developmental juncture and in the familiar relationship context in which they found themselves at that time. Expose to unusual challenges over a long period is likely to lead to character-‘de’ formations which drive a range future ‘schema based’ behaviours which may not have a coherent surface structure but nonetheless share a common root, which if addressed then helps to undo the apparently chaotic branches.
4. Dodo- bird- horses for courses : I know what follows is crude- but I do think that there is a relationship between the complexity of client problems and the complexity of treatments designed to address them.
I think that it is fair to want to spend public money cost effectively, and that this might mean that we recommend a symptomatic standardised ‘treatment’ as a first response to what looks like a symptomatic simple response: “every time I am scared I overbreathe and get a panic attack.”. If “every time I am scared “resolves into “every time I am scared of x- and almost only when I am scared of x”, then a deconstruction of that perceived threat into a decision tree with a new repertoire of adaptive responses may be a perfectly good way of helping this person overcome the problem that brought them into therapy. Such a procedure can be taught to a number of health professionals during a short and inexpensive training via a manual and they can carry out a procedure competently which will help a large number of people with such ‘simple’ panic attacks.
If it turns out that such a procedure fails , a more highly trained professional may need to reassess the client and may then uncover ‘generalised anxiety with an underlying ‘neurotic’ character structure’ which will require a more expensive therapeutic response by a more highly trained professional who is competent in ‘negative capability’, deep listening, suspension of preconceptions, intuitive tailor made empathic responses and perhaps above all the capability to emotionally contain, hold, transform or manage considerable anxiety and aggression in the patient/client…
In short: I believe there are families of approaches which may be theoretically diverse within the family, but where families are characterised by a reasonable match between client and therapist factors which revolve around the
complexity
severity
chronicity
intractability
of the client’s difficulties as well as client factors such as
psychological mindedness
intelligence
social connectedness
temperament and personality so forth
Clients who are temperamentally non compliant may not respond to a treatment or a professional normally adequate for addressing the problem itself and they are likely to need a much more experienced and resourceful therapist with the skill to engage the client in the first place and the resources needed to prepare the client for such a treatment by working first with characterological issues.
Allan Zuckoff, 13 Marzo 2006
Tullio wrote:<< …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>>.
Dear All,
It’s hard for me to say this without being as offensive as Tullio, which is not my intention, but I don’t get the sense that those on this thread who are criticizing manualized treatments have much actual experience with them. Though it’s certainly possible to write a manual badly—that is, to provide a rigid, simplistic series of steps the therapist must take, which can be performed by any semi-competently trained technician, and which ignores critical common-factors therapeutic skills including capacity for empathy, alliance-building, flexibility, etc.—I have not personally been involved with such projects. I have, however, provided protocolized treatments in open pilot and randomized studies of supportive-expressive therapy, complicated grief treatment, motivational interviewing, and interpersonal psychotherapy. I have also written and adapted manuals in a couple of these areas. And here are a few of the things I’ve experienced and learned:
- Doing manualized complicated grief treatment, which integrates a modified-exposure-based CBT treatment with elements of interpersonal psychotherapy and a little motivational interviewing, was among the most challenging and rewarding experiences of my professional life. Despite being a fairly structured treatment, it also required of me the skillfulness I have developed over 15+ years of psychotherapy practice. And, not only did it quantitatively outperform interpersonal psychotherapy, which (as many of you will know) is a much less-structured therapy that most dynamic therapists would not find unfamiliar, but my personal experience as therapist was of participating in remarkable transformations in clients’ lives in startlingly little time.
- Doing supportive-expressive psychotherapy with cocaine addicts (in NIDA’s collaborative trial) would have been less difficult and more effective if the manual and manual supplement we were provided were a bit more specific and mutually consistent.
- Learning and practicing semi-structured motivational interviewing has made me a better dynamic/humanistic therapist (and I was pretty damn good already).
- Many (if not most) practicing therapists would benefit from the discipline, fresh thinking, and humility required to learn and integrate a new, manualized treatment.
I also am acutely aware that this “dialogue” has been lacking much input from others on this listserv who view therapy manuals and randomized controlled trials not (of course) as the be-all and end-all of psychotherapy research, but as one approach that can provide important information (if complemented by process and qualitative research). If this is the best the SEPI listserv can do, then what are the prospects for dialogue among therapists of multiple persuasions in the wider world?
Paul Wachtel, 13 Marzo 2006
Dear Allan.
I agree with you that manualized treatments need not be as simplistic and limited as they are sometimes portrayed. And it may even be, as you suggest, that at least some manuzlized treatments provide benefits over and above those of doing similar work in a less structured and predictable way. But that is an empirical question, and the problem with the way that manuals have become fetishized in the field is that the more extreme advocates of manualization have insisted that only with a manual can an outcome study provide valid information about the effectiveness of a therapeutic approach. Backed by the political and economic power of managed care companies and other representatives of the "cheaper is better" corporate approach to health, research funding sources too are hesitant to fund outcome studies that do not include manuals. This, of course, makes it impossible to answer (or even pose, except hypothetically) the empirical question. How can you compare a manualized treatment with a non-manualized treatment if only a manualized treatment can be included in funded research? The rules are tendentious. They stack the deck. They imply, by definition that a non-manualized treatment cannot be "empirically validated" since empirical validation, according to these skewed rules, requires manualization. It is both illogical and logically airtight, and the conclusions are foregone ones.
So I don't have any disagreement with your own arguments, which really are for a measure of mutual respect between proponents of different paradigms, different procedural inclinations, and different visions of how the need for some kind of empirical validation is to be pursued. But I have a great deal of disagreement with those who, in a mix of subtly (and not so subtly) disguised ideology and self-interest insist that outcome studies that do not employ manuals are either or both unfundable and invalid. That is politics, not science.
Allan Zuckoff, 13 Marzo 2006
Dear Paul,
Thank you for your response. I agree without reservation with every word you have written here. I believe that researchers need to be able to describe the therapy they are testing, and provide some way of ensuring that the therapists doing the therapy are doing it well and with integrity (true to the approach). Manuals and their accompanying adherence/competence scales are only one way of accomplishing this, but politics (or perhaps ideology) has cursed the field of psychotherapy research for decades with mutual disrespect and polarization.
In fact, here’s a tantalizing tidbit from an area I know very well: in a meta-analysis of controlled studies of motivational interviewing (MI), Hettema, Steel, & Miller (2005) compared studies of MI that did and did not use a manual (amazingly, a number of non-manualized studies have gotten funded by various sources). The overall effect size for manualized MI = 0.35; for non-manualized MI, 0.65. At least part of the explanation for this comes from a study, led by Bill Miller (the developer of MI), in which (he has since publicly concluded) he did a poor job of writing the manual, by insisting that all patients receive a certain element of the intervention whether or not they were ready (a clear violation of MI principles). So it may be that some kinds of therapy are interfered with if done according to a manual, while other approaches are aided by manualization; or that some manuals are better than others; or that how one teaches a therapist a manualized therapy influences how well that therapist performs it; and so on. The complexity is great, and clearly one answer does not fit all circumstances.
George Stricker, 13 Marzo 2006
I would like to add one point to Paul's comment, and it is from the standpoint of someone who respects data and would like to see science contribute more to practice (and vice versa). RCTs, which are held up as the gold standard, and certainly are very powerful in terms of internal validity, almost always have symptom change as the criterion. This is not necessary, but it seems to work out that way, and it does give the apparent advantage to treatments that focus on treatment rather than relationship pattern or character change.
Allan Zuckoff, 13 Marzo 2006
Dear George,
I agree wholeheartedly with your comment as well. To paraphrase (or in this case, butcher) Nietzsche again, a philosophy’s most vociferous adherents should not be seen as evidence againstit.
Tullio Carere, 14 Marzo 2006
Dear all,
I apologize for having expressed my dislike for manualized treatments in a way that has been perceived as offensive by someone who likes them, as Allan. I'll try to reformulate my ideas on this topic in a more respectful way.
A key concept in my view is that of metaprocedure (the patient's experience of a procedure). The basic point is that the therapeutic factor in psychotherapy is not the therapist's behavior (whether or not one calls it procedure), but the meaning the patient gives to the therapist's behavior and the interaction in which it is embedded. This is partially true already in medicine, although here the patient's subjective experience is disregarded as placebo, and only the "specific action" is considered. The separation of the objective from the subjective component of a therapeutic act is questionable even in medicine, but is definitely weird in psychotherapy. Manualization of psychotherapy is an imitation of objective medicine, which implies the separation of the active ingredient (the manualized procedure) from the placebo (the patient's subjective response). The idea that a therapist should not regulate his or her interaction as a function of the feed-backs they uninterruptedly receive by the relationship, in other words they should not be true to the process as it unpredictably develops moment by moment, but to a manual written by a well meaning researcher, creates a new thing that I would hardly still call psychotherapy.
The real thing to me, the thing I call psychotherapy, is process-oriented. But the Zeitgeist has invented a new thing, procedure-oriented, that many choose to call by the same name of psychotherapy, because of a superficial resemblance. Yet the new thing is not only a radically different thing, but I dare say a mortal enemy to the old, as Barry clearly enough observed:
<<…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 seachange in what was called "fundable psychotherapy research" because I knew it sounded the virtual death knell for psychotherapy process research. I lost!!>>
Process-oriented therapy is complex. As Hilde notes,
<<Complexity almost always goes hand in hand with uncertainty, unpredictability, making ‘ one problem- one solution’ scenarios unlikely. Therefore , manualised therapies which work in ‘one problem- one solution’ situations- for which they were designed, are unlikely to be able to deliver change.>>
It requires
<<a more highly trained professional who is competent in ‘negative capability’, deep listening, suspension of preconceptions, intuitive tailor made empathic responses and perhaps above all the capability to emotionally contain, hold, transform or manage considerable anxiety and aggression in the patient/client..>>
Now, Allan, why should you take offence if I say that manualized "psychotherapy" is a totally different thing as process-oriented psychotherapy? And that I cannot see any possible dialectical synthesis between the two? Manualized psychotherapy is a process killer (but it is not easy to kill the process, as the Dodo bird knows well). Yet I can accept that in some or many cases a rapid symptom reduction could be desirable regardless of the development of a psychotherapeutic process, and in these cases a manualized psychotherapy could be a viable alternative to medication. Therefore, I don't object to the existence and the possible usefulness of manualized psychotherapy: I only object to the unfortunate confusion between the two things.
Is this contribution more palatable? I am afraid not. Sorry, at least I have tried.
Luca Panseri, 14 Marzo 2006
Allan Zuckoff wrote :
<< Many (if not most) practicing therapists would benefit from the discipline, fresh thinking, and humility required to learn and integrate a new, manualized treatment>>
Allan, this is an interesting point I have thought of a lot of times. I often tried to approach some manualized treatments but I was never able to read and practice them thoroughly. I got bored, annoyed and above all I found them too distant from what Tullio calls “real treatments”.
Honestly I often asked myself whether my attitude towards manualized treatments was due to a lack of discipline and humility for my part.
For example, as many others on this listserv, I got the EMDR certificate but it was a real pain. I couldn’t do and say what the teacher wanted me to do and say, not because I am so undisciplined, but because I couldn’t bear a simulation/situation in which “the technique” was put at first place while the other fundamental elements of the relationship had to be submitted to the protocol. In particular with EMDR you had to follow, at least during the training, the eight steps in a very rigid and restricting way. Said that, in my clinical experience I found very useful to sometimes introduce the ‘bilateral stimulations’ but in a way which held no resemblance with the stereotyped descriptions of the manuals. And I was very reassured about my (supposed) lack of discipline and humility when I read, beyond the official Shapiro’s manuals (in my opinion strongly supporting the Shapiro’s economical empire) other more creative and liberating writings of therapists like Paul Wachtel who were able to free the bilateral stimulations from the straitjacket of the STANDARDIZED EMDR. As Paul wrote in his article ‘EMDR and Psychoanalysis’ : “…strictly speaking, the work I will describe here is not EMDR. As it is presently defined, and presently practiced, EMDR is a highly structured treatment with a very specific set of steps and procedures. What I will describe is a way of working that is inspired by EMDR, that draws upon some of the key elements of EMDR, but it differs quite substantially from the way EMDR is most typically practiced”.
Actually I think that every time we are with our patients and not in the simulated situations of manuals and training our work differs quite substantially from the way A CERTAIN TECHNIQUE is (supposed to be) most typically practiced”.
Therefore back to what Allan wrote, maybe some therapists would benefit from learning and working in accordance with manualized treatments but others, with different temperaments and attitudes, had better learn them and quickly forget them in order to follow what the clinical situation really requests and not remain stuck with the steps the different protocols require.
Tyler Carpenter, 14 Marzo 2006
Dear Tullio and Luca,
The more I listen to and think about the points I hear you both make, the clearer it makes me think about what I share with you both in terms of how I work. At the same time, paradoxically, the harder I find it to understand why I simultaneously find others' remarks about integrating research findings and the value of manualized approaches so compatible with my own thought and practice. Luca's description of his experience of EMDR training was quite similar to mine. However, I struggled to be more disciplined in my adherence to the technique itself primarily because I found it so enjoyable to have the experience in that format myself (even if it isn't critical to the therapeutic effect of the technique). The remarks I made in my Psychotherapy Research book review of Francine's "Paradigm" text on EMDR from other perspectives, similarly appreciated the light chapters like Paul's brought to an understanding of the EMDR phenomenon. Luca's description of how he incorporates EMDR concepts is quite similar to mine. And then I had a bit of a flash: I assimilate and accomodate all techniques and theories in a similar manner, whether they come from manuals, empirical articles or more dialogic approaches or wherever. Years ago I remember learning how so many modern artists move from classical learning to modern expression. I was subsequently less floored when reading about Miles Davis development (I have taken up my trombone after 40 years absence from playing to retackle the golem of jazz improvisation which discouraged me from developing my already fine technique so long ago) to learn that he rarely listened to jazz, but in fact he listened more contemporary French composers and classical music. In fact this catholic approach to enjoying assimilating other styles and genres of music than one's own music is one many musical performers adopt. I understand from a recent tome on the development of the trombone that the post-modern musician's approach to playing requires such an eclecticism in order to survive financially. Perhaps the most unstructured approach I ever adapted to or incorporated parts of was Robert Langs' Bipersonal Field framework. When years ago I listened twice to a 12 hour sequence of his tapes while driving across Iowa and Kansas, I was alternately appalled and enthralled by the somewhat paranoid, but extraordinarily sensitive approach to the nature of the interrelated technique and therapeutic relationship in his way of working. When I tried out the concepts in practice I found the conceptual framework was tremendously powerful. Some years back a senior colleague suggested to me that I seemed to have a way of thinking and working similar in style to Lacan. Although I've since come to believe his remarks were more a way of gently appealing to my narcissism and helping me to extend my understanding by reading this great man's work, it also alerted me to my tendency to incorporate (maybe even ingest) and play with new concepts in such a dramatic and reorganizing way at times as to make them my own and helpful to my patients and comprehensible to my colleagues in discussions. If this is the case, then it isn't hard for me to see myself as quite open and philosophically compatible with both empirical and dialogic approaches as long as I can use them in a way that I understand and is demonstrably useful to those I seek to help.
George Stricker, 14 Marzo 2006
In general, I am not a fan of manualized treatments. However, rather than "learn them and quickly forget them in order to follow what the clinical situation really requests and not to remain stuck with the steps the different protocols require," as Luca suggests, wouldn't we be better off learning them, adapting them, and drawing on them as relevant in our clinical situations?
Luca Panseri , 14 Marzo 2006
George,
When I say “quickly forget them” I’m referring to a mental attitude – the “negative capability” Hilde mentioned- that can be cultivated only if we are willing to let go all our (supposed) knowledge (included the steps of a protocol) and be open to whatever happens in the clinical situation.
Tullio Carere, 15 Marzo 2006
George and Luca,
the two positions described by you go beautifully hand in hand in the assimilative-accommodative integration: George's assimilative, Luca's accommodative. But you both clearly have both arrows in your quivers.
Allan Zuckoff, 16 Marzo 2006
Dear Luca,
Many thanks for your thoughtful and non-defensive response to my rather pointed comment. Allow me to say, as an initial disclaimer, that I feel much the same way about the therapeutic empire-building evident in institutionalized EMDR as you do. In the therapy community I feel at home in, that of motivational interviewing (among whose membership can be found several other members of SEPI), there is a semi-directive therapeutic method with various structured interventions adapted from it, all well-described in books and manuals. But there is no hierarchy and no for-profit accreditation process (indeed, as yet, no official “certification” at all); training materials are “open source;” and the developer of the approach has publicly described how one manual he wrote led to a failed controlled trial because it was “wrong for the right reason”—precisely in having forced therapists to be rigid in their performance.
That said, my main response to your post is this: It is both more difficult, and potentially more rewarding, for an experienced and skillful therapist to learn a structured, manualized therapy, than for a novice to do the same. More difficult, because (ironically) it requires just that form of epoche that has been described as the sine qua non of process-oriented psychotherapy—but in this case, it is a willingness to suspend preconceptions about what “good therapy” is, long enough to enter and understand the world of the novel treatment. More rewarding, because after the initial, epoche-facilitated learning is done, the wisdom of previous experience can be brought back into play, allowing for the integration of what is valuable in the new, into the richness of what was there before.
So I think that what you have described is the natural process of an experienced therapist’s genuine encounter with a novel therapeutic techne, which is what George has also, I think, been describing. And isn’t this what Paul Wachtel described himself as doing before writing the seminal book on psychotherapy integration that is as responsible as anything for the existence of SEPI?
Allan Zuckoff , 16 Marzo 2006
Tullio,
Gaslight, they say, was ever-so-much-warmer than the electric lights we now rely on. But gaslights were also comparatively inefficient, and apt to explode—and refined electric light turns out to be capable of a warm and mellow glow. But what Luddites always fail to recognize is that new ways of doing things can often incorporate that which remains valuable from the old ways.
Although you seem unwilling to understand this, well-written manuals provide for the complexity and variability of “real” therapeutic encounters. When I do “manualized” therapies, I am highly attentive to process, empathy and its vicissitudes, alliance and misalliance… In some cases, these factors are central to the therapies as described in their manuals; in others, they are less explicitly described than they should be, but just as necessary (and their relative presence or absence undoubtedly accounts for those famous “therapist effects”). Yet the “procedures” I follow allow me to accomplish more than I could by using only the process-focused procedures you rely on.
And this is because meaning is not “given” to others’ behavior, but inheres for us within it; when others perceive our behavior, they perceive that inherent meaning, from their own perspective (with all that implies). Otherwise, it would be possible to attribute any meaning to any given behavior, which of course is absurd. Because the perspective that clients bring to their encounters with us co-constitutes the horizon against which our behavior appears, our “same” behavior may be more or less therapeutic for different clients, and we need (as a profession) to understand this in ways which thus far have eluded us (as a profession), and to learn how to tailor whatever procedures we engage in more individually. But the procedures are what they are, and your “process-oriented” approach is just as much subject to these truths as are more “structured” interventions.
The thing to which you arrogate the term “psychotherapy” is the form of therapeutic encounter I love most. (I, too, have some of the Luddite in me.) And, if my choice were determined primarily by what I find most “comfortable” (to use your word), it’s probably all I would do. But I’ve learned that doing a semi-directive form of client-centered therapy called “motivational interviewing” often allows me to help addicted clients change their lives with remarkable rapidity. And I’ve found that, by doing a structured, experiential / cognitive-behavioral form of therapy with clients with “complicated” (a/k/a traumatic) grief, I could help them come to accept the death and reengage in a meaningful life in months rather than years. And these experiences made it clear to me that my comfort level had to take a back seat to the well-being of those I serve.
Hilde Rapp, 16 Marzo 2006
Dear Allan, Tullio, George, Luca, Tyler and others on this thread,
I greatly appreciate the trouble everyone is taking to explain their position with such care and good grace. I apologise that some of my recent contributions have not been very conversational but rather hasty bullet points…
I wonder whether we are struggling with the distinctions between capability, competence and excellence? I am a member of professional registration board and very similar discussions have taken place there to those on this list about how one should define what senior practitioners do and how this could possibly be done justice to in a formal portfolio based assessment…
There are other functions also, such as standardizing a set of interventions for research purposes…), but it seems to me that one important function of manuals is to aid the cost and time effective training of junior therapists in order to equip them with the basic capability to practice safely and effectively under supervision so that they may with practice become competent independent therapists. (I have a supervision menu which systematically tests for certain competencies, on of which is the capacity to work coherently, consistently and creatively within the therapeutic model which informs their practice, and which could be specified in a manual).
Manuals are the distilled essence of what senior practitioners see as the lineaments of competent professional practice, broken down into units of competence, organized into a protocol with accompanying guidance of how to assemble these units flexibly into a treatment plan which structures a sequence of therapeutic actions designed to achieve certain therapeutic goals safely and effectively.
When a senior practitioner uses such a manual, one of two things may happen ( to simplify hugely) .
The first is – if the therapists is in tune with a protocol driven approach- the manual will act as a prompt to bring all their experience and expertise to bear on the clinical situation. Then their performance will be- to all intents and purposes- indistinguishable from that of a therapist who practices without a manual- as was of course the case for the therapist who wrote the manual in order to capture his or her non manualised prior practice. What you get is excellence. The manual does not and cannot capture excellence- it is only capable of capturing competence and it aims to do just that.
The second is what happens when someone like Tullio, who is committed to excellence, believes that in order to adhere to the manual he must scale down his performance to be merely competent, and he experiences this as a painful loss of finesse, complexity and depth.
However- and Allan, you have already made this point very eloquently- excellence is excess, excellence is practice open to the noumenal, unshorn of all the excess meanings that real experience and depth of feeling, and the analysts among us might say, the unconscious, and the analytical psychologists might say, the archetypal and transpersonal bring to our practice. This can not be described or prescribed- by a manual, because it is something that can only be lived ( we sometimes call this the quality of the therapists presence- some people might even think of the therapeutic encounter as the locus in which the divine or transpersonal manifests through an act of grace, and by definition, grace cannot be bidden.)
Despite Tullio’s fears, excellence is not pro-scribed by the use of a manual: A manual is like a karate kata, in that it constrains a sequence of therapeutic moves. The performance of a yellow belt and that of a black belt master practitioner contains the same sequence of moves. However, while the yellow belt is, through practice, developing her basic capability to move towards competence, the master is performing her moves with the strength, discipline, presence of mind, skill, fluidity, art, grace and focus characteristic of excellence- and we can all tell the difference… To change metaphor, excellence is due to the personal qualities of the actor ( this includes George’s therapist factors), not due to the letters of the script- however good.-
So, dear Tullio, fear not to be shorn of excellence by submitting to a certain discipline…
Tyler Carpenter, 16 Marzo 2006
I wonder whether we all, from novice to senior practitioner, work at the confluence of capability, competence and excellence, Hilde ? However, what the senior clinician may experience more frequently is what Mihaly Csikszentmihalyi calls flow and that is both what happens when we're fortunate and in part why we do what we do.
Not long after I wrote my last response I lay down to listen to Chet Baker's heart breakingly beautiful CD "You Can't Go Home Again." On it Chet was revealing how he had come back from his darkness and his friend Paul Desmond was there to accompany him and three months from his own death. The liner notes contain the following 1938 quotation from a talk the author Thomas Wolfe gave at Purdue five months before his own death:
"I did not know that for a man who wants to continue with the creative life, to keep on growing and developing, this cheerful idea of happy establishment, of continuing now as one has started, is nothing but a delusion and a snare. I did not know that if a man really has in him the desire and the capacity to create, the power of further growth and further development, there can be no such thing as an easy road. I did not know that so far from having found out about writing, I really found out almost nothing...I had made a first and simple utterance; but did not know that each succeeding one would not only be...more difficult than the last, but would be completely different, that with each new effort would come new desperation, the new and the old, sense of having to begin again at the beginning all over again; of being face to face again with the cold naked facts of self and work; of realizing again that there is no help anywhere save the help and strength that one can find within himself."
This is a little dramatic in some ways, but captures what I look for and find when I really try on something new, whether from a manual or wherever, and really look at it and feel what I could only look at and feel in part before. When this happens with the patient there is nothing better and we and the staff know it. However, what I really see and feel more deeply is just how much we all can see that we didn't see before and how important it is that we not call it or try to reproduce it in a way that can only obscure the subtlety of the experience and it's irreproducible evanescence.
Tullio Carere, 16 Marzo 2006
Dear Hilde and all,
I remember one of my first trainer analysts who used to say: "This is the theory and this is the technique, but in the analytic hour forget all about that. Just be there". She never used the expression 'freedom from memory and desire', but this is what she meant. It is a basic principle of the philosophia perennis, which one also finds in phenomenological epoché, in za zen, and in many other disciplines. In your terms, she wanted us novices to learn excellence in the first place, not competence. So, to the other variations of the basic dichotomy (manualized vs. non-manualized, theory centered vs. dialogue centered, stereotyped vs. heuristic, procedure oriented vs. process oriented) we could add this one: excellence oriented vs competence oriented.
The process (or dialogue, or excellence) oriented therapist follows a line which I (today) would call of assimilative- accommodative integration. In this line one can assimilate virtually anything into one's home theory, even manualized methods - but then, whether or not the assimilated thing is originally manualized is irrelevant, because in any case the manualization is lost in the process of assimilation (see for instance what happened to EMDR when assimilated by Paul, Luca, Tyler, and myself). The process of assimilation is a heuristic, not an empiric affair. You cannot be dialogue-centered and procedure-centered at the same time. You cannot be the servant of two masters, you have to choose. Either you choose to be silent inside, and through this silence you open the space in which genuine dialogue happens, or you have a mind full of algorithms. A mindful mind is not a mind full of things.
What the process oriented therapist (either senior or novice) aims at fostering, is what Csikszentmihalyi calls flow, as Tyler reminds us. In the flow all memory and desire, of both patient and therapist, of course return. The therapist's memory includes all theories and techniques assimilated in years, but they turn up in the analyst's mind in the same way as all other associative material. A piece of a behavioral technique can be as relevant as a scene of the picture I saw last night to the understanding and the processing of the present material. And how do we decide what is relevant in this very moment? The procedure oriented therapist consults his/her mental diagnostic and therapeutic manuals, trying to match the appropriate procedure to the problem or need in question. The process oriented tries to understand what the process requires in this very moment, and to respond fittingly. In so doing he/she does not draw on manuals but on common sense, i.e. the noetic-dianoetic function (the dialectic of intuition and reason) that is the basic competence of every human being.
To the development of this basic competence, the procedure oriented therapist counterposes more specialized competences. I do not object to this choice, provided that one does not object to mine. This discussion has helped me appreciate the protocol oriented therapy for the treatment of special conditions or for the training of therapists who are not interested in becoming process oriented or for public services and third payers who are more symptom-reduction sensitive. The two lines of psychotherapy integration can coexist but still don't meet, at least in my mind. You say, Hilde, that "excellence is not pro-scribed by the use of a manual", and compare manuals to a "karate kata, in that it constrains a sequence of therapeutic moves". I understand your example. In karate, as in many other disciplines, technical competence is the basis, and excellence develops, when it develops, on this basis. The karateka must firstly be competent, and then possibly excellent, in his/her art, and the same is true for the protocol oriented therapist. Competence is not conflicting with excellence, to the contrary: one has to be competent in one's specific discipline, before becoming excellent. Your example is well chosen: the aim of the karateka is to win the fight, as the aim of the protocol oriented therapist is to defeat a symptom. But dialogue is different. The only thing you have to fight in dialogue is your own ego and its epistemophilic drive. You don't fight symptoms as a rule, because who knows, the patient could need this symptom right now. The ego grows stronger when it knows many things, many procedures. The only thing a dialogue centered therapist wants to know, is that he or she knows nothing.
Can the two lines of psychotherapy integration be combined, as most of you maintain? Maybe they can, although I still cannot see how. Yet, for the time being, it seems to me far more important to distinguish them than to combine them. You know what happens when one melds a strong thing with a weak one, don’t' you?
Hilde Rapp, 16 Marzo 2006
Dearest Tullio,
I am so touched by your struggle! As you know my homeland is dialogue and the dialogic imagination. I can see that psychotherapy education (I prefer this to training) can make a native preference and sensibility toward dialogic and relational ways of engaging with others more refined. We can with practice and reflection become more competent at dialogic forms of engagement.
The distinction between competence and excellence is akin to that between techne- craftswomanship and arts- artistic fluency. Many people can become good craftspeople and make very serviceable furniture and bronze castings exhibiting good workmanship, pleasing design and fitness for purpose. In a busy city we need many tables and chairs and a few good sculptures too, and hence many craftsmen and women good at making them. As you can see my metaphor predates the age of the technical reproducibility of the work of art that Walter Benjamin talks about so brilliantly. In the spirit of this metaphor, I am sure you would grant me that many of these highly accomplished craftsmen or women nonetheless never achieve the flair and elegance and beauty that would take our breath away so that we say that this is a truly excellent chair of Bauhaus quality- in fact, really a work of art or that this pleasing figurine in our garden has the breath of Rodin upon it.
There maybe schools of carpentry that only ever aim for training craftsmen, but many such schools would hope to provide an education that will bring out and help to flourish any artistic talent their students might have- ah! here at last we have our very own Thomas Chippendale…
So, give a manual for making a chair to a Mies van der Rohe, and he will make you a work of art. Apprentice someone to a Michelangelo and he might still never become a true master, and he might not even become a good craftsman because the necessary steps in the process were always implied but never spelt out in a way that they could be followed, repeated and practiced…. and you would not buy his statue for your garden.
Every metaphor only carries us so far, and every transference might want to carry us in the opposite direction…
Like you I have worked hands on in the health service and I have seen many services at primary, secondary and tertiary care level in a role where I have been responsible for ensuring that they actually made a difference to peoples wellbeing.
I have unfortunately seen services which spent a lot of money on serving a very small number of people without being able to show what results they had achieved in moving their patients from the clinical spectrum to the non clinical spectrum because they used no outcome measures at all.
In many cases this money can be better spent by offering much less ambitious , more symptom oriented therapy to a much lager number of people moldering on waiting lists over twelve or twenty four sessions, by using treatments such which have been shown by research to improve the lot of particular client populations. This approach may be manualised, and if so, it is even more likely that a service can actually track and monitor outcomes perhaps even with the option of linking outcomes to therapist behaviours. Also people can be trained to use such approaches much less expensively. Many people will get better by working with a good craftsperson- because a craftsperson is not just a professional, they are –as you say good human beings, sensitive, full of good will and many other things which normally come out as ‘common factors’. They are common to human beings, they are not common to people because they have been put there by a training- they were already there. The training helps to refine and direct our way of being with people so our learnt repertoire of interventions can be brought to bear.
There are many people who cannot so helped and who do need a truly dialogic engagement in order to reach into their difficulties. If money is saved by helping people who can and will improve with procedural interventions, then more money is available for those who need an artist in order to get back on their feet, or to get onto their feet for the first time. A four tier service model would accommodate such an approach to meeting client needs- where treatments become more complex and lengthy and resource intensive as the client’s difficulties become more complex, severe chronic and pervasive…
I would never argue that we should only have procedural approaches, manualised or not, or only have dialogic approaches, or that all dialogic approaches should teach procedures and vice versa. I am only arguing that there is need to have space and respect for understanding why we may choose one approach or another, and when and where one choice may be more appropriate than another- and these reasons are usually justified on pragmatic grounds, rather than on theoretical ones. Therefore my understanding of integration is at the meta framework level that I have briefly mentioned and which I will say more about in Florence. It is heuristic that allows us to make clinical decisions on the basis of client need. Theoretical allegiance can alto readily lead to a supply led system, which as Mike Basseches puts it, may do serious ‘violence to the clients meaning system’.
I can imagine a world in which all therapists are excellent and all governments have the money to fund only excellent therapies- and if it ever comes to pass I will move there tomorrow.
I live in a world where a cash strapped service competes with housing and education to meet people’s needs, where therapy trainings are lengthy and cost at least 30 000 dollars and where people from ethnic minorities have little choice but to enter trainings which will equip them in a shorter time and at a lower cost with the essential knowledge and skills (competencies) to help members of their community who are currently poorly served by white middle aged therapists who are informed by ethnocentric theories. So my votes goes to them.
However!!! I will at the same time campaign energetically for us to walk on the hard road to that other world where dialogue and inspiration flourish and serve to empower people to lead full and creative lives. I hope and wish that we can shorten the gap between what is and what might be by working together internationally as we are right now, thanks to you, Tullio.
Mike Basseches, 16 Marzo 2006
HelloTullio, Hilde, et al.
Well, reading Tullio's post that arrived on this side of the atlantic this morning and finding myself heartily agreeing!, I was already again regretting that I haven't been able to follow every word of this wonderful dialogue, but feeling drawn in enough to hit the reply button, hoping that over time today I could figure out if there was anything I wanted to say besides, "right on, Tullio.". Then reading Hilde's response, what I wanted to say became clearer, only to discover as I read further on that she had already included me, by citing me. (Thank you, Hilde!) I think that I basically agree with Hilde that the contributions of all therapists to their clients' well being, across all forms of training and degrees of expertise, should be very much appreciated, and fostered. Nevertheless, the first point she makes below, as well as the later sentence in which she cites me, lead me to want to add this little caveat or clarification to Hilde's idea of a four-tier service model. In recognition of the harm done to clients when Tullio's "procedure-oriented therapist" fails to recognize that the procedure isn't working for a particular client (or worse, recognizes it and "blames" the client for not responding appropriately to a treatment, empirically-validated or otherwise), it seems important that all therapists' education aim at the epistemological sophistication needed to locate appropriately whatever they "know" about any procedures that they use (and whatever they do in whatever tier they are working) within the sort of broader "psychotherapy integration" universe that Tullio, as well as others in SEPI, have been working so hard to describe.
Granting Tullio the "poetic license" to overstate it and oversimplify it a bit in the interest of dramatic expression when he says, "The only thing you have to fight in dialogue is your own ego and its epistemophilic drive. You don't fight symptoms as a rule, because who knows, the patient could need this symptom right now. The ego grows stronger when it knows many things, many procedures. The only thing a dialogue centered therapist wants to know, is that he or she knows nothing.", I would agree with the following claim: Given a choice between a psychotherapy integration that rests on the foundation of recognition of what we don't know (as well as what we tentatively do know) and of the processes by which we together with our clients discover more, and a psychotherapy integration that rests on holding tight to what we do know and assimilating as much as possible to it, the former does seem like the sounder choice.
Hilde Rapp, 16 Marzo 2006
Dear Mike, dear all
Thanks for the caveat- well taken! Meta- frame works rely on meta-cognition- and meta –cognition is thinking about thinking- and thinking about thinking always leads to questions, not answers. I am quoting myself to say that a good therapist needs to know when to ask good questions and when to wait for the client to ask them him or herself! (procedures can be very helpful at generating good questions…they may be less good at dealing with pregnant silences…)
Tullio Carere, 19 Marzo 2006
Dear Mike, Hilde and all,
Thank you for supporting me in the struggle for the priority of unknowing over knowing, and for forgiving my "poetic license" in overstating my case. You most fittingly draw attention to the harm done to clients when the diagnose-and-procedure-oriented therapist "fails to recognize that the procedure isn't working for a particular client (or worse, recognizes it and 'blames' the client for not responding appropriately to a treatment, empirically-validated or otherwise)". The theoretical abuse, as you properly call it, is the risk inherent in any theory-driven therapist unable to neutralize their theoretic allegiance and to dwell in a theory-free space. To minimize this risk, you (and I) deem it important that "all therapists' education aim at the epistemological sophistication needed to locate appropriately whatever they 'know' about any procedures that they use (and whatever they do in whatever tier they are working) within the sort of broader 'psychotherapy integration' universe" that I have tried hard to describe. This implies that the sort of "psychotherapeutic craftsmanship" currently happening and empathically described by Hilde should not be encouraged, unless it is preceded by a proper psychotherapeutic education.
This is what Allan too seems to maintain, when he suggests that protocol-driven procedures should be used by therapists who have "critical common-factors therapeutic skills including capacity for empathy, alliance-building, flexibility". They can therefore use a protocol-driven procedure with enough detachment as to able to recognize when it does not work for a particular patient. Consequently, they would modify it to adapt it to the present situation if possible, or would abandon it at all. In this case the danger of theoretical abuse would be shunned, and a comparison would be acceptable between a manualized and a non-manualized treatment. But this comparison will not be easy, until non-manualized approaches will have equal possibility of being funded than the manualized, as Paul points out. Anyway, in the meta-analysis of controlled studies of motivational interviewing (MI) that Allan fairly quotes the overall effect size for manualized MI is 0.35; for non-manualized MI, 0.65. To say the least, so far we don't have much evidence showing the advantage of manualized over non manualized therapies.
I would emphasize the following points:
1. We should beware the danger of scientism and technicism currently plaguing our field. The basic education of all psychotherapists should be informed by a dialogical attitude based on the development of the capacity of deep listening and of relating in the basic modes corresponding to the critical relational common factors.
2. On this base every school, group and individual therapist could assimilate all sorts of theories and techniques, as a function of preferences, chances, and fields of application. But this assimilation could happen in two radically different ways: one is empirical, the other is heuristic, corresponding respectively to the procedure oriented, and the process oriented approach.
3. The procedure oriented approach is theory driven. The procedure must be manualized in order to prove its efficacy in the treatment of a specific disorder, and the protocol must be applied faithfully enough to ensure its empirical validity.
4. The process oriented therapists remain true to their basic dialogical attitude. They have of course theories and techniques, but these are just a component of the therapist's person that is at stake in the dialogue like any character trait, no more and no less: surely they are not the principles guiding the therapy. To the contrary, they are bracketed all the time in order not to saturate the space of the dialogue.
5. In the research, the procedure and the process oriented approaches should have equal possibilities of being funded. In the evaluation of the results, symptom reduction should not be the main criterion. Relationship pattern or character change should be at least equally rated.
This is what is clearer to me now, thanks to this wonderful discussion, and what I am going to say in my presentation in Florence, save further corrections due to your feed-backs in the next days.
Tyler Carpenter, 19 Marzo 2006
Tullio, at the risk of being misperceived, perhaps, the only way I can describe your synthesis is to call it lovely! Although I'm not sure that it is possible, perhaps you might try to apply the same lyricism (what George B. Murray referred to in part as "limbic music") and poetics in/to your description of the more instrumental and scientific approaches, as you do with the dialogic. I keep thinking that if I didn't know the practical importance of your theoretical position, I would be left feeling that I was a part of the undesirable "other" if I identified my self professionally with the characteristics you describe as belonging to the theory driven therapist. I suspect that the very experienced therapist is likely to appreciate, if not savour your analysis (sorry or not for the choice of descriptor). However, the less experienced or more theory identified therapist may not be able get around the subtle, but negative emotional valence attached to what epistemologically is also just a position and is not without its negative, but less elaborated effects on the patient.
Perhaps there's no getting around the conflict inherent in such discussions. It sometimes seems to me that to attempt to divest a statement of all its potential for negativity and conflict, is to forget what we understand about the nature of the process we are attempting to treat and suck the essential
meaning from the life we and others are all a part of.
George Stricker, 19 Marzo 2006
I don't think I disagree with any of Tullio's broader conclusions, and clearly am not a manual-driven therapist. You also, quite correctly, in my view, call attention to "the harm done to clients when the diagnose-and-procedure-oriented therapist fails to recognize that the procedure isn't working for a particular client (or worse, recognizes it and 'blames' the client for not responding appropriately to a treatment, empirically-validated or otherwise)”. However, in putting together your presentation, which most of us will not have the benefit of hearing, you might want to consider what happens when the process oriented therapist fails to recognize that the procedure isn't working for a particular client. In understanding the fallibility of all of us, it is important not to close off any tools, procedural or process, and to be open to whatever we may learn about any of the approaches. It also means we have to be able to fund the full panoply of approaches, something that we are not doing at the present time.
Mike Basseches, 19 Marzo 2006
So Tullio, if you're asking for any more "corrective thoughts" before presenting Florence, I have thoughts about how I would respond to Tyler's concern. If I read you right, Tyler, you are concerned that there is an, however small, "demonizing" element to Tullio's position. I think what Hilde and I have both tried to communicate are the following points, which are efforts to counteract such "demonization": 1. Every single therapist has the potential to contribute valuable resources to clients' developmental struggles, and to the effort in therapy to create new and valuable personal knowledge, and this is something that we should all celebrate, and incorporate into our advocacy for psychotherapy. 2. Every component of psychotherapy training, whether it takes the form of a new theoretical idea, a new procedure or technique, or a new research finding about psychotherapy -- manualized or not, or a new proposed integrative synthesis, has the potential to augment the resources that any given therapist has to offer. This too we should all celebrate, and incorporate into our advocacy for psychotherapy training and research. The engagement in psychotherapy practice, training, theorizing, and research, on anyone's part absolutely should not be demonized. But the dialogical common ground on which I, and I believe Tullio, would like us all to meet, is the recognition that the arena in which any psychotherapeutic knowledge or ideas, whatever their source, must ultimately be "validated", is in the dialogue/relationship between therapist and client in which further new knowledge can be co-constructed, and the impact of that new knowledge on the lives that the client and therapist live beyond that relationship. If some would exclude others from even entering that arena, or would create funding mechanisms and principles such that many are de facto excluded because they can't afford the ticket of admission, this is indeed a problem and the one that Tullio may be addressing. I think that both the humility reflected in recognizing the need to subject any psychotherapy practice, whether procedure or process-oriented to this acknowledgment of fallibility and process of validation, is what George has appealed for in his recent post, while also arguing for non-discrimination and maximizing access. Do I get you right, George?
If there is a negative side to this epistemological position, I am probably somewhat blinded to it, and so Tyler, I would certainly appreciate your clarifying what you think it is.
Tullio, I appreciate your bringing all of us along, even if we can't be in Florence physically. If I find myself seeing any of the beautiful sights of Florence in my dreams, I'll understand why. Best wishes, and please let us know how the presentation goes.
Tyler Carpenter, 19 Marzo 2006
As the saying goes, Mike, "The devil is in the details." Depending on how a position is framed, there is a "negative" side to every position which is the point I was trying to make in quoting Lao Tzu. However, it is my understanding that ancient emperors and periods of Chinese culture supported Buddhism, Confucianism, and Taoism precisely because of what each, separately and in concert, brought to the lives of the people and the culture. A forensic colleague recently pointed out when describing a delightful graduate school admissions interview he conducted with Taiwanese candidate, when asked if the candidate had a particular philosophical preference, he (candidate) said, "When we want to do something correctly we quote Confucius. When we want to take a nap we quote Lao Tzu." Sometimes one's a samurai and at other times a ronin. I found both yours and Hilde's and George's and Allen's and Paul's points all quite helpful and thoughtful in their ways, Mike.