Dibattito postcongressuale
2° CONGRESSO S.E.P.I. ITALIA Firenze 24-26 Marzo 2006
Allan Zuckoff - 25 Aprile
Tyler Carpenter - 25 Aprile
Allan Zuckoff - 25 Aprile
David Allen - 25 Aprile
Tyler Carpenter - 26 Aprile
Mark Dworkin - 26 Aprile
Pagina 2 >>
Tullio Carere, 28 Marzo 2006
Cari amici e colleghi, un forte e sentito ringraziamento a tutti per l'eccellente Congresso di Firenze, ricchissimo di stimoli e insegnamenti. Voglio dare subito inizio al dibattito post-congressuale a partire da una questione su cui la mia posizione è cambiata rispetto all'inizio del congresso. Vi riassumo in breve la mia tesi, per dirvi poi in che cosa è cambiata. Ogni terapia è caratterizzata da un processo, unico e irripetibile, e da procedure, più o meno rigorosamente definite da manuali. Il rapporto tra processo e procedura è quello tra figura e sfondo: se è in primo piano il processo, la terapia sarà di tipo processuale. In caso contrario l'approccio sarà di tipo procedurale. Certamente in ogni terapia ciò che sta sullo sfondo viene a volte in primo piano, e viceversa, ma in generale i due stili di lavoro sono ben distinti. Questa distinzione corrisponde alle due anime dello psicoterapeuta: l'anima del medico e quella del filosofo. Il primo vuole diagnosticare un disturbo e curarlo con procedure conformi all'inquadramento eziopatogenetico prescelto nel modo più efficace, rapido ed economico possibile (orientamento molto ben rappresentato al congresso da Giorgio Alberti, che nel suo intervento ha messo a confronto il manuale cognitivo comportamentale di Judith Beck con quelli psicodinamico-esperienziali di Fosha, McCullough e Osimo). Il secondo vede invece la terapia come un processo virtualmente interminabile di autoconoscenza, crescita di consapevolezza, liberazione del potenziale creativo e generativo; il disturbo non è una lacerazione da riparare al più presto per una restitutio ad integrum, ma qualcosa di cui cogliere il senso nella globalità dell'esistenza di una persona e da inserire all'interno di un progetto esistenziale (posizione limpidamente rappresentata da Diego Napolitani). Nel congresso io ho sostenuto che, per quanto sia augurabile che ogni terapeuta abbia entrambe le frecce al suo arco, tra i due approcci si pone una questione di scelta piuttosto che di integrazione: o piuttosto, di una integrazione subordinata a una scelta primaria (nel senso che per esempio un terapeuta processuale dovrà integrare nel suo approccio un insieme di procedure di cui comunque non potrà fare a meno). Ma indubbiamente ho descritto la polarità processo-procedura in modo più dicotomico che dialettico (in contrasto con il mio stile abituale). Il motivo di questa dicotomizzazione, che a congresso concluso riconosco eccessiva, sta nell'aver preso troppo sul serio le pretese della EBT (Evidence Based Therapy), da una parte e dall'altra dell'Atlantico. Per restare dalla nostra parte, da anni Gianni Liotti sostiene, e ha ribadito anche nel dibattito precongressuale, che la psicoterapia deve trasformarsi, e si sta già trasformando, in una scienza normale come la medicina. In passato Gianni ha dichiarato esplicitamente di voler considerare la psicoterapia come un ramo della psichiatria, che a sua volta è una branca della medicina. Se consideriamo che la gran parte della ricerca in psicoterapia è costituita dagli outcome studies o RCT (Randomized Clinical Trials), che in medicina sono considerati il gold standard della ricerca empirica (anche la ricerca in psicoterapia ha adottato questo standard, come ha ricordato Paul Wachtel), sembrerebbe logico che l'evoluzione naturale della nostra disciplina, nella sua trasformazione in 'scienza normale', sia verso la prescrizione di procedure manualizzate empiricamente supportate per i disturbi per i quali si applicano. Invece nel congresso c'è stata una generale presa di distanza dagli outcome studies, a cominciare da Paul Wachtel, per il quale esiste una varietà di metodi scientifici (al plurale) per ridurre l'autoinganno o la distorsione delle nostre conoscenze, e che ci raccomanda di guardarci dallo scimmiottare (parrot) la fisica o la medicina, a scapito della specificità della nostra disciplina. Salvatore Freni ha poi ricordato che l'attività scientifica comincia già quando ragioniamo sull'esperienza, e che la scienza empirica è solo una specializzazione del metodo scientifico di base che consiste nel dubitare sistematicamente, nell'interrogarci sul significato delle nostre esperienze, nel formulare ipotesi e cercare dei dati che le confermino o le confutino. Ma soprattutto Gianni ha dichiarato senza mezzi termini che è una stupidaggine dare un'importanza fondamentale agli outcome studies, che costituiscono solo una minima parte della ricerca scientifica. Ora, a me sembra che se quella è una stupidaggine, allora è una stupidaggine anche pensare alla psicoterapia come un ramo della medicina, per la quale invece gli outcome studies sono assolutamente fondamentali. Cosa che io ho sempre pensato, per cui non posso che rallegrarmi del fatto che Gianni abbia cambiato idea (se non ho capito male). Ma allora in che cosa consisterebbe questa integrazione della psicoterapia sulla base della ricerca empirica, su cui Gianni sempre insiste? Abbandonati al loro destino gli outcome studies, il focus si sposta su altre ricerche, soprattutto quelle che studiano i sistemi emozionali/motivazionali che emergono dai processi evoluzionistici. Gianni si è soffermato sullo studio empirico delle basi intersoggettive di questi sistemi, fornendo nella scoperta dei 'neuroni specchio' un esempio di come la ricerca empirica possa fondare scientificamente la pratica psicoterapeutica. Il 'monitoraggio metacognitivo delle emozioni' permette di dare un fondamento empirico a nozioni come l'empatia o l'identificazione proiettiva. Questo ancoraggio dovrebbe aiutare il terapeuta a distinguere, nel monitoraggio delle proprie emozioni, quelle che 'rispecchiano' l'esperienza dell'altro dal 'controtransfert' (come Gianni chiama la componente 'non rispecchiante' delle emozioni del terapeuta, usando il termine in un'accezione un po' desueta). Pier Francesco Galli ha subito preso la parola per dire quello che avrei voluto dire anch'io (ma Galli lo ha detto molto meglio di quanto avrei saputo fare io): queste sono cose che noi facciamo da sempre, che cosa ci dicono di nuovo per noi queste nozioni di neurofisiologia? In che modo la pratica e la teoria della psicoterapia sono arricchite, o in qualsiasi modo modificate, da queste nozioni? Le risposte di Gianni non hanno soddisfatto minimamente Galli (né me stesso), ma non sappiamo come si sarebbe sviluppato il confronto se Zapparoli, preoccupato (o annoiato) per l'escalation emotiva di quel contraddittorio, non lo avesse interrotto. Gianni mi ha poi detto, fuori della sala prima di andarsene (il suo treno stava per partire) di avere già dei dati che mostrerebbero la superiore efficacia di un approccio terapeutico dotato di questa base empirica rispetto a un approccio simile, ma privo di quella base. Io gli ho risposto che se la ricerca empirica permette di produrre buone metafore, come questa dei neuroni specchio, capaci di migliorare significativamente la nostra pratica, ben venga: ma non ho fatto a tempo a esprimergli la mia perplessità, che esprimo adesso. Come facciamo a stabilire che l'uso della metafora dei neuroni specchio migliori effettivamente la psicoterapia rispetto a chi non ne fa uso? È chiaro che dovremmo fare degli studi clinici randomizzati. Ma se lo facessimo, dovremmo ammettere che l'ultima parola per stabilire se gli studi di neuro scienze sono utili alla psicoterapia spetterebbe agli outcome studies, che tornerebbero quindi a essere fondamentali. Ma come possiamo farlo, una volta che abbiamo stabilito che è una stupidaggine assegnare loro questo ruolo? Alla fine del congresso mi sembra che della fondazione empirica della nostra disciplina rimanga ben poco (ma forse mi è sfuggito qualcosa: prego Gianni di correggermi o illuminarmi). Io avevo visto una dicotomia tra approccio procedurale e approccio processuale perché, come ho detto, avevo dato credito alle pretese della EBT. Ma se, come mi sembra ora, queste pretese sono alquanto infondate, la dicotomia cade per lasciare posto a un continuum tra polo processuale e polo procedurale, al cui interno un terapeuta può muoversi liberamente tra un polo e l'altro, oppure scegliere di collocarsi prevalentemente da una parte o dall'altra. La continuità è garantita dal fatto che di regola la scelta e l'uso delle procedure, anche se basate su manuali, avvengono su base euristica, e non empirica. Scusate per la lunghezza di questo contributo: prendetelo come il mio discorso conclusivo del congresso, che non c'è stato tempo di fare, e come lo spunto iniziale per il dibattito post-congressuale.
Giorgio Alberti, 29 Marzo 2006
Caro Tullio,
ho letto con piacere e interesse il Tuo mail di ieri, e ora Ti invio qualche osservazione come si dice, a caldo. In primo luogo sono perfettamente d'accordo che il II Congresso SEPI-Italia è stato un gran successo, e non solo quanto a partecipanti, ma quanto a qualità e ampiezza dello spettro dei confronti. E ciò è da ricondurre a Te e al Tuo entusiasmo, oltre che naturalmente a Rolando Ciofi e Patrizia Adami Rook, con la loro apertura laica e pluralista e la loro capacità organizzativa. E' insomma un evento da ricordare, anche per l'altissimo livello della partecipazione degli americani, e soprattutto, a mio vedere, in quanto segno del fatto che l'interesse per l'integrazione non è più cosa di pochissimi "visionari" (e metto tra questi me e Te) ma è ormai un movimento nel senso più proprio: un numero sempre più grande di persone, soprattutto giovani, ha capito che pluralismo, confronto, valutazione laica di validità teorica e efficacia sono elementi cardine della moderna psicoterapia. Non so se Ti ho detto che pochi giorni prima, e per l'esattezza il 14.3.06, si è discussa presso la Scuola di Specializzazione in Psicologia Clinica della Facoltà di Medicina dell'Università Statale di Milano quella che a mio sapere è la prima tesi in campo integrativo, su "Associazione e combinazione di interventi psicoterapeutici eterogenei: modalità ed efficacia" fatta da una mia allieva. Alla fine del congresso di Firenze sono poi restato piacevolmente stupito nell'apprendere che un altro psicologo si è laureato qualche tempo prima con una pregevole tesi su "I fattori terapeutici della psicoterapia", pubblicata in forma di libro presso l'editore QuattroVenti. Il fatto stesso che a Firenze vi fossero più di 150 partecipanti significa certo qualcosa anche al di là dell'innegabile livello dell'organizzazione. In un certo senso io credo che forse sarebbe ora di fare ciò che discutemmo qualche anno fa, ritenendolo però prematuro, e cioè una costituzione formale della SEPI-Italia in società scientifica, con suo statuto, organi, finalità, congressi e così via. Pensiamoci (e questo invito è rivolto ovviamente a tutti i partecipanti alla lista). Ma ora vengo a un punto del Tuo mail, quello che mi riguarda, e non solo perché, appunto mi riguarda, ma anche perché una sua pur breve discussione dovrebbe riverberarsi su altri temi di interesse generale. Parlo quindi del 2° capoverso, e in particolare del punto in cui Tu parli delle due anime dello psicoterapeuta. Ora, devo ammettere che Tu hai ben caratterizzato la mia personale posizione in questa prospettiva: io ritengo che per me la psicoterapia non sia principalmente un processo virtualmente interminabile di autoconoscenza, di crescita di consapevolezza, di liberazione del potenziale creativo e generativo, bensì la risposta a un disturbo, a una sofferenza, fondata possibilmente su una comprensione diagnostica psicogenetica e su interventi possibilmente trasparenti, efficaci ed efficienti veicolati dalla parola e dal rapporto terapeuta-paziente. Tuttavia, ciò non significa che l'obiettivo sia, nella mia prospettiva, una restitutio ad integrum, una restaurazione dello stato pre-sofferenza, anzi è, io ritengo, un avanzamento evolutivo fondato sul superamento di modi controproducenti di vivere e relazionarsi, che può essere accompagnato da un 'espansione della capacità di godere e creare, rapportata ovviamente alla dotazione, alle priorità e ai valori del singolo. Non solo, la posizione procedurale, di cui mi fai alfiere massimo, non va vista come se si trattasse di curare attraverso un rigido ed esclusivo repertorio di procedure da innescare ogniqualvolta vi sia l'indicazione, ma consiste nel tentativo costante di fondare il curare sulla consapevolezza delle azioni e degli atteggiamenti (od omissioni) che si mettono in atto, e del loro rapporto con un esito, iniziale, intermedio o finale, sì da costruire un percorso di avvicinamento all'obiettivo della cura che nella prima fase si è più o meno precisamente definito. Questo modo di operare dovrebbe fondarsi, oltre che sulla conoscenza del singolo paziente, anche su conoscenze di carattere generale, riguardanti probabilisticamente anche il singolo soggetto che abbiamo davanti. Qualche esempio. Un primo, molto generale e generico: se ho ragione di credere che il paziente sia affetto da un disturbo della personalità di tipo borderline o narcistico, sarà sbagliato offrirgli troppo precocemente, o senza accompagnargli degli interventi ansiolitici supportivi o d'altro tipo, dei commenti sul mio rapporto con lui, o addirittura un' interpretazione del suo transfert verso di me. Perché, come ormai è diffusamente dimostrato e quindi ben acquisito, è altissima la probabilità che, più o meno scopertamente, il paziente si ritiri dalla relazione, cioè che io crei una rottura (v. Safran e Muran). Uno ora un po' più specifico. Se ritengo che il paziente non abbia un disturbo di personalità grave, e ravviso nel suo modo di porsi nelle relazioni una tendenza a compiacere eccessivamente l'altro, dovrò pormi il problema di come mostrargli questo suo pattern: riferirmi a eventi esterni alla seduta piuttosto che a eventi occorsi in seduta, cercare ad esempio di avviare una sua auto-osservazione e condurlo a individuare il pattern nei suoi rapporti con gli altri e con me. Dalla letteratura sull'interpretazione di pattern disfunzionali, compresa l'interpretazione del CCRT, so che un paziente non troppo disturbato può trarre molto dall'illustrazione plausibile e empatica dei suoi modi abituali di porsi in certe situazioni: da un lato quanto alla relazione (sappiamo che si sentirebbe capito e accolto, e che la sua eventuale ansia diminuirebbe) dall'altro quanto a informazioni su di sé e quindi quanto a spunti per eventualmente modificare quel suo modo di porsi controproducente. Spero che questi esempi mostrino, oltre che il riferimento a conoscenze empiricamente validate, anche la difficoltà e lo sforzo di adattamento di esse al singolo caso, nel quale, proprio come succede con altri rimedi, l' azione della procedura è influenzata da molti elementi nuovi, riferibili all'unicità della personalità del paziente e al grado di conoscenza che ne ho, all'incontro relazionale tra me e lui, alla mia capacità di essere lucido e di vedere in tempo e con precisione le diverse situazioni intrapsichiche e relazionali, e ad altri fattori ancora. Perciò ho parlato di attinenza probabilistica delle conoscenze della ricerca psicoterapeutica al singolo caso. Quindi queste conoscenze sono sempre e solo un indicatore della direzione che probabilmente sarà più proficua, ma non sono precetti religiosi da osservare alla lettera. Non solo, la messa in atto delle procedure dipende anche dalla mia capacità, come ho già accennato poc’anzi, di essere lucido, oppure di essere automaticamente corretto e opportuno. Se in altre parole le procedure sono fissate nella mia memoria procedurale sarò in grado di metterle in atto, almeno in parte, in modo automatico, ad esempio, una volta deciso "lucidamente" di fare un certo intervento, nella scelta delle parole più opportune dato il paziente, nell' avvicendamento delle varie fasi (introduttiva, centrale, conclusiva etc.), nella scelta del tono della voce e così via. Ecco, spero di aver precisato almeno un po' ciò che a Firenze, in un qualche intervento, ho illustrato attraverso la metafora dello sciatore, che non pensa certo lucidamente ad ogni procedura che mette in atto, che la esegue automaticamente, pur adattandola alla situazione del momento, e che però, soprattutto, in un qualche momento precedente ha certo dovuto imparare le procedure in modo più analitico (non psicoanalitico), lucido, poco fantasioso ed anche forse barboso.
Sergio Benvenuto, 29 Marzo 2006
Caro Tullio, Vedo che non ti schiodi dalle tue arcinote dicotomie. E noto anche che, di fatto, quello che ho detto al convegno (per non parlare di quello che ho scritto nel corso degli anni) ti e' entrato da un orecchio e ti e' uscito dall'altro. Prova ne sia che non fai il minimo riferimento al mio intervento... Ahimè, viaggiamo per galassie del tutto distanti.
Tullio Carere, 30 Marzo 2006
Caro Sergio,
non mi sembra che le nostre galassie siano così distanti. La mia dicotomia è la stessa che proponi tu, solo che è più sfumata (e lo è ancora di più a congresso concluso). C'è una corrispondenza notevolissima tra la tua dicotomia (psicoanalisi vs. trattamenti tecnocratici) e la mia (approccio processuale vs. procedurale). Intendiamo sostanzialmente la stessa cosa. Certo, ci sono delle differenze. Il mio approccio processuale (psicoterapia come Bildung, il terapeuta come filosofo) è un po' più vasto della tua concezione a mio parere un po' ristretta e antiquata di psicoanalisi, che respinge la dimensione relazionale. E il mio approccio procedurale (il terapeuta come medico) è ben più dignitoso del tuo approccio tecnocratico-mercantile. Ma con diverse sfumature e valutazioni ci riferiamo chiaramente alla stessa dicotomia. Ci siamo tutti dentro, è inutile negarlo. Meglio prenderne atto e vedere assieme che cosa farne. Tipicamente le persone che negano la dicotomia lo fanno precisamente come fai tu: dicono che la dicotomia non esiste semplicemente perché svalutano e denigrano quello che sta dall'altra parte. Ma sarebbe più onesto ammettere che la dicotomia è nell'ordine delle cose, che è un effetto delle due anime del terapeuta. E poi vedere se è meglio 'integrare' queste due anime in qualche modo, oppure sceglierne una mettendo in sordina l'altra (ma l'altra non si lascia mai mettere del tutto in sordina). Inoltre, io sono molto d'accordo con te nel ritenere che la psicoterapia sia un'operazione fondamentalmente etica, quindi aperta a molte scelte e che non deve essere 'normalizzata'. Ma credo che questa libertà di scelta non si difenda proclamando un'orgogliosa 'psicoanalisi per il principe' - cosa che scatenerebbe solo la reazione dei proletari tecnocratici che tu disprezzi - bensì lavorando perché anche le terapie di tipo processuale possano dimostrare la loro efficacia con ricerche di tipo documentale (e non sperimentale, come forse un po' ingenuamente, ma con molta buona volontà, cercano di fare i sostenitori delle terapie procedurali). Su queste cose credo che dovremmo discutere. La tua insistita polemica antidicotomica ha avuto peraltro come effetto che, a causa dei tempi congressuali ristretti, non sia venuto a sufficienza in luce quello che considero il tuo contributo più prezioso alla definizione di approccio processuale (alias psicoanalisi). E' un tema su cui io lavoro da anni: quanto più si lascia il processo libero di fluire senza essere ingabbiato da ipoteche teorico-tecniche, tanto più emergono delle regolarità costanti, riconoscibili in tutte le pratiche processuali indipendentemente dalla teoria del terapeuta: i cd fattori comuni. Ora, anche tu hai definito una triade di fattori o atteggiamenti generali che caratterizzano ogni pratica processuale (alias psicoanalitica): episteme, phronesis o prudenza, e retorica. Ma di queste il fattore cruciale è il secondo, la prudenza, o psicoprudenza, come dici con un neologismo ricalcato su giurisprudenza ("il buon giudice non è chi sa scientificamente, ma chi, conoscendo bene le leggi e i codici, avendo senso della giustizia ed esperienza della vita, di caso in caso elabora soluzioni 'prudenti' appunto, che concilino giustizia e legalità"). Questi tre fattori si trovano indubbiamente anche nelle terapie processuali, ma con uno spostamento decisivo di enfasi: mentre "la prassi del tecnico - in politica come in psicoterapia - si basa su quella che i greci antichi chiamarono episteme", quella del terapeuta processuale si fonda sulla 'prudenza', sulla capacità di trovare di volta in volta soluzioni 'prudenti', capaci di 'integrare' di volta in volta le conoscenze acquisite, i dati disponibili e le evidenze intuitive. E' una distinzione intrigante e stimolante, ed è un peccato che non la si sia potuta discutere in sede congressuale. Ma possiamo farlo adesso. Per cominciare, può il nostro massimo esperto di terapia procedurale, Giorgio Alberti, riconoscersi in questo primato dell'episteme sulla 'prudenza'?
Tullio Carere, 2 Aprile 2006
Sono tornato dal congresso SEPI di Firenze con l'impressione che il prestigio dell’Evidence-Based Psychotherapy (dove l'evidenza è principalmente quella degli outcome studies o RCT – Randomized Clinical Trials) sia in caduta libera. Gli outcome studies sono ormai considerati marginali (marginali ma non irrilevanti: Liotti; così marginali da essere irrilevanti: Luborsky, Wampold, Messer ecc.) per diversi motivi. I principali sono elencati nel lavoro di Westen citato da Paolo Migone. Ma se anche questi studi non avessero tutti i difetti che hanno, è ormai chiaro a tutti che l'applicazione protocollare di un manuale è ad alto rischio di abuso teoretico (la forma più comune di abuso dei terapeuti sui pazienti: Basseches). Niente da dire sui manuali, se sono applicati con buon senso e adattati alle circostanze, al singolo paziente, alla singola seduta (come al congresso hanno raccomandato Norcross e Alberti): e non per fare della 'terapia manualizzata'. Ma così torniamo, per fortuna, al buon senso clinico, e il fatto che un manuale sia o non sia "empiricamente supportato" è del tutto irrilevante.
Questa però non è la fine dell'evidence. Mentre gli outcome studies sono abbandonati al loro destino, non viene meno la voglia di fondare la psicoterapia sulle certezze epistemiche fornite dalla ricerca empirica. Le certezze che non si sono trovate indagando le psicoterapie con i metodi della medicina si cercano ora altrove, sul terreno delle neuroscienze o della ricerca di base di psicopatologia dello sviluppo. In particolare al congresso Liotti si è soffermato sullo studio empirico delle basi intersoggettive dei sistemi emozionali/motivazionali che emergono dai processi evoluzionistici. La scoperta dei 'neuroni specchio' sarebbe un esempio di come la ricerca empirica possa fondare scientificamente la pratica psicoterapeutica. Ora, io non ho motivo di dubitare che i dati della ricerca empirica possano arricchire la teoria e la pratica terapeutica di chi ha bisogno di questo tipo di supporto. Ma per affermare che una psicoterapia dotata di questo supporto sia da qualsiasi punto di vista migliore di una che ne è priva, occorrerebbero degli studi clinici randomizzati, precisamente quelli che sono stati dichiarati marginali. Visto che su questi non si può più contare, rimane comunque una risorsa che non viene mai meno, la fede incrollabile nella scienza come fonte di sicurezza. Molti oggi si sentono bene se possono poggiare i piedi su questo terreno solido, forse gli stessi che ieri stavano bene sul terreno delle certezze di scuola, rassicurati dalle parole dei maestri e dei testi sacri. Per molti l'importante, oggi come ieri, è non rischiare di pensare con la propria testa.
Ma anche su questo torno da Firenze con buone notizie. La scienza unica, compatta e trionfante, che procede con gli stessi principi dall'ameba a Einstein (come piaceva a Popper) non ha più il credito indiscutibile e intoccabile che aveva nel mondo psi fino a pochi anni fa. Sempre più si parla di diversi approcci scientifici (Wachtel), e soprattutto di metodo scientifico di base, che non consiste in altro che osservare e riflettere sulle proprie osservazioni (Freni). Il terapeuta è lui stesso uno scienziato, uno 'scienziato locale' (Striker e Trierweiler), nel momento stesso in cui pensa. Meno pensa, più ha bisogno che altri pensino per lui. Più pensa, meno ha bisogno del 'supporto' altrui. In particolare quello, di cui c'è oggi un'offerta martellante, della ricerca empirica. Viceversa, una testa pensante è sempre in grado di valutare criticamente i contributi provenienti da altre teste pensanti. Incluse quelle dedite alla ricerca empirica.
Tullio Carere, 9 Aprile 2006
I am pleased to inform you that the Florence SEPI-Italy conference was successful beyond expectations. And, as far as I am concerned at least, very useful, to the extent that I came out of it seeing things differently from how I saw them before. I was 'healed' from the dichotomy between an empirically supported psychotherapy integration, and a common sense, assimilative-accommodative integration, that seemed to me necessary to house two radically different and incompatible souls in one conference. I was healed because I learnt, to my relief, that an empirically supported psychotherapy hardly exists in the real world of psychotherapy, as represented at the conference by the twenty plus speakers of all theoretical persuasions.
Firstly, the outcome studies (or Randomized Clinical Trials) were declared "marginal" even by the most dogged supporters of empirical research as a foundation for psychotherapy integration. Not just for the many flaws of these studies, but because it is by now clear to everybody (John Norcross put much emphasis on this point) that procedures - all procedures, even those which are protocol driven - must be customized or tailored on the unique characteristics of the individual patient, of the patient-therapist relationship, and of the session or phase of the therapy. Manuals can be useful, provided that they are not used to do manualized therapy. Customized, not manualized therapy is the right thing.
When a procedure is customized, it is irrelevant whether or not it has been studied in a protocol form (i.e., whether or not it is "empirically supported"), because the empirical support applies only if the procedure is administered in the conditions in which it was empirically studied: i.e., in the manualized, not in the customized mode.
Secondly, with the marginalization of the outcome studies the hopes for an empirical support to psychotherapy moved to other sectors of empirical research, particularly those of developmental psychopathology and neurosciences. In this regard, it is clear that some discoveries in these fields (e.g., styles of attachment or mirror neurons) have enriched the theory and practice of those who need such support to their therapeutic work. Yet, the conviction that a therapy grounded on such empirical ground be in any respect better than one which is not, should in turn be supported by empirical studies like the RCT that have just been declared marginal. So far, there exists no empirical support to the idea that empirically supported therapy is better than one which is empirically unsupported. The one thing we can say, is that some therapists are happier if they can think that their thing is empirically supported (and we know that all sorts of therapies work better if the therapist believes in his or her method, whatever the justification of their belief).
This is not to say that scientific research is useless. Paul Wachtel and I agreed, over a caffelatte, that the therapeutic couple should produce objective material, like recordings, post session questionnaires or written notes by both the patient and the therapist, to be examined and studied (also) by third parties in order to uncover significant correlations between process and outcome. Whether or not this documental (not experimental) research is deemed empirical, is not a question that might keep me awake at night.
A warm thank you also to our third international speaker, old friend Hilde Rapp, for her constant support to the whole conference.
David Allen, 10 Aprile 2006
Tullio,
I think treatment manuals for outcome studies can be modified so that, within the parameters of the treatment model under study, a certain degree of flexibility for the therapist regarding "customizing" the treatment to the patient can be built in. Clearly any intervention, no matter how customized, can be judged as being consistent with a particular school of thought or, more accurately, not consistent with a particular school. The manual would also have to be "customized," just like the treatment, for the particular stage of therapy that the treatment is at. For almost all schools, some therapist interventions that are appropriate at the beginning of treatment are inappropriate at later stages, and vice versa.
While this sort of alteration of the typical treatment manual would reduce scientific rigor to some extent, it is still a lot better than just taking a therapist's word that what he or she did was effective. How else do we know that the therapist under study is not just making wild guesses about what should work or not for a particular patient, and not basing it on any particular methodology? How else do we know that what the therapist did led to the results that were obtained, or instead that it was due to some extraneous factor? How else can we compare the effectiveness of different therapists, and different therapies?
It seems to me that for a long time, psychoanalysts in particular used the logical fallacies of begging the question ("This works because I say it works") and ad hominem combined with begging the question ("You are challenging the analytic theory, which means that you need analytic therapy to find out why you can't accept this") to avoid offering any kind of evidence that what they were doing actually accomplished some goal. Furthermore, if the goal of treatment can not be defined and measured, at least in general, how do we differentiate therapy from any other type of metacommunicative conversation?
Alberto Zucconi, 12 Aprile 2006
Caro Tullio,
le mie sincere congratulazioni per il successo del II° Congresso SEPI di Firenze. La tua fatica e quella degli altri organizzatori è giustamente premiata da questo risultato. Ottima la scelta d'invitare John Norcross, Hilde Rapp e Paul Wachtel, il loro contributo è stato molto significativo e penso abbia giovato a tutti i colleghi italiani ed in particolare a coloro che per problemi di lingua non hanno molte occasioni per riflettere sui loro contributi. Per questo motivo penso che la tua opera sia di particolare significato in Italia, ove a mio avviso ancora esiste in alcuni ambiti il problema dell'autoreferenzialità. Se il campo della psicoterapia italiana progredirà, e di questa crescita abbiamo veramente bisogno, questo sarà grazie a sempre maggiori possibilità di sereno confronto e scambio con gli esponenti dei vari approcci a livello nazionale ed internazionale. E' senz'altro apprezzabile il contributo fornito a questo processo dalla SEPI.
Per quanto riguarda la ricerca in psicoterapia, ritengo che essa sia una condizione necessaria anche se non sufficiente per la crescita del nostro campo, non solo e non tanto per i suoi risultati "oggettivi", ma per la necessità da parte di tutti noi di porsi delle domande sull'efficacia e l'efficienza dei servizi che eroghiamo, e di come formiamo i nostri allevi e per il processo di cross-pollination con colleghi di vari orientamenti e nazioni, tutti accumunati dallo stesso imperativo deontologico: operare in scienza e coscienza nell'interesse dei nostri utenti.
Tullio Carere, 15 Aprile 2006
David:
Susan Oyama has beautifully exposed the fallacies of conventional, genecentric evolutionism, according to which the genes have 'programs', or at least 'predispositions' that are implemented by the organism to produce the phenotype, which more or less is a 'copy' of the genotype. Living systems don't work like that. The genes are just means, or resources, like the cards in a bridge game (metaphor mine). The game is not the implementation of a program inscribed in the cards, but the construction resulting from which cards are played and when (genes are differentially activated at different times in different tissues), and the decisions to play a card instead of another depend on many complex and unpredictable factors (Oyama: "cell lineages are complex and unpredictable"). The phenotype, like the bridge game or any other living interaction, is not the implementation of a program, but a construction in which many different levels are implied, in very complex and hardly predictable ways. This is specially true of a psychotherapy session (see for instance the research of the Boston Change Process Study Group, which illustrates how much "sloppiness" generates unpredictable and potentially creative elements that contribute to psychotherapeutic change). The process that Oyama calls construction, Bergson called creation one century ago (nothing to do with intelligent designs, of course).
In the evolution/development of living systems one can describe specific patterns, e.g. reliable genotype/phenotype or patient/therapist correlations. A good bridge player, as a good therapist, is knowledgeable about many such patterns, on which they draw to devise the best strategy in a single game or session. However, this happens in a context with many variables, which the good player or therapist must carefully consider to customize the pattern to the present situation. This might be the explanation of the result of the meta-analysis by Hettema and al. quoted by Allan Zuckoff: the same pattern (motivational interviewing) rated much better when applied in a non manualized, than in a manualized mode. The two modes correspond respectively to ordinary clinical experience and to empirically supported treatments.
Coming to your questions after these premises: If you apply a pattern with the necessary attention to what is specific and unique to the single situation, in other words with the necessary flexibility, you do what all good clinicians do, no more and no less. You don't operate in a manualized mode. This is what I call "real therapy", and this, I believe, should be the object of our study. We all surely agree that "just taking a therapist's word that what he or she did was effective" is not enough. We need documentation (recordings, post-session questionnaires, written notes by both patient and therapist) to study the process and correlate it to the outcome. This material allows us to compare the effectiveness of different therapists, much more than of different therapies (the Dodo bird and I don't believe much in different therapies). Of course, we should not beg the question of what in the interaction with our patient correlates with a given outcome. But I don't share your faith that this question can have objective, measurable answers. We can trace the crucial event or series of events that brought about a change, and describe them in a coherent, persuasive, experience-near, almost theory-free way. But the significant events in psychotherapy are cognitive and emotional experiences, only understandable in light of the meanings and values given to whatever transpires in the relationship. Research in psychotherapy, as in all evolutionary or developmental phenomena, is bound to be mainly qualitative (descriptive), not quantitative (statistic), given the unique features of any single process.
David Allen, 15 Aprile 2006
Tullio:
What I'm proposing is a different type of manual than the ones currently used in "empirically supported treatments." I don't disagree with your characterization of how a good therapist proceeds, nor with the importance of process research. However, process research can only tell us what sequence of interventions and responses probably led to a certain outcome in one patient. As you imply, the very same sequence in a similar-appearing patient might lead to quite a different outcome. I also agree that following a manual of cookbook interventions, rather than a manual consisting of a list of possible strategies for how to play out the bridge game you're talking about, does not approximate what a good therapist actually does. While the bridge player has a selection of cards to play, however, the selection is nonetheless limited to the cards in the player's hand. Therapist's possible responses are likewise numerous but nonetheless limited in number by the theoretical perspective the therapist employs. I believe that all good therapists choose different arrows from their quivers based on a theory, whether they are able to articulate the theory or not. Otherwise the therapy would be chaotic.
Because of various factors, any particular sequence of cards played by a given bridge player in response to the moves of other players within the confines of the hand the player is dealt will not guarantee a win. Nonetheless, some sequences are more likely to produce a "winner" (or in therapy, lead to a desired outcome) than others. To look at what you were saying below in a slightly different way, the best bridge players are those most knowledgeable about these probabilities. Likewise, certain strategies in therapy will work more frequently to solve a given therapy problem - that is with a higher probability of success - than others. Even the most powerful strategies will fail some of the time, and those with a lower probability of success will on occasion work like a dream. It's all probabilistic, not determinative. In order to know what strategies are the most likely to succeed with a patient who is responding to interventions in a particular way, one has to look at collective data on therapies employing the various strategies. The plural of anecdote is indeed data, if the anecdotes are collected in a somewhat rigorous way. The measurements, because human behavior is so complex, will of course be far less precise than those in a physics experiment, but I don't think that means we should abandon the effort to look at therapy from the collective rather than the individual vantage point. The end results of such a methodology for a given clinical problem would hopefully look like a bell shaped curve of different therapist interventions and another bell shaped curve of patient responses to those interventions. The therapist could start with those interventions with the highest probability of success, but move to other ones if the patient's reactions fall outside of one standard deviation within the normal patient response curve, metaphorically speaking.
In a manual I've devised for my model for treating patients with self destructive personality traits, Unified Therapy, I try to define the primary goals for each stage of therapy (for example, getting a "borderline" patient to accurately describe certain repetitive ongoing interactions with members of his or her family of origin that serve as triggers for the patient's problematic behavior). These goals can be achieved using a fairly wide variety of strategies, any one of which can (and must, if the therapist is sticking to the manual) make sense within the confines of my theory. If the desired results (getting the detailed descriptions of the interactions, in this case), do not occur, the therapist must try a different strategy, and keep altering the strategy as needed, based on the responses of the patient, until the goal is achieved. In order to adhere to the manual, this is the sort of flexible approach the therapist must employ.
Of course, getting an outcome study funded to see if this works is a whole different issue!
Allan Zuckoff, 15 Aprile 2006
Tullio wrote:
<< A good bridge player, as a good therapist, is knowledgeable about many such patterns, on which they draw to devise the best strategy in a single game or session. However, this happens in a context with many variables, which the good player or therapist must carefully consider to customize the pattern to the present situation. This might be the explanation of the result of the meta-analysis by Hettema and al. quoted by Allan Zuckoff: the same pattern (motivational interviewing) rated much better when applied in a non manualized, than in a manualized mode >>.
Tullio,
Here's the thing about a bridge game: you're either in or you're out. If you're in, you have to play by the same rules as all the other players, you have to play whatever cards are dealt (whether you like them or not), and you have to see the game through to the end. If you try to take a trick and then claim victory, you're going to get an awfully frosty reception the next time you want to play. So, before invoking findings from controlled quantitative studies to support one's position, one must first decide: am I in the science game, or not? Hettema et al's meta-analysis found larger effect sizes for MI in studies that did not use a manual than in those that did. And for those of us who give credence to randomized controlled trials, this is certainly a thought-provoking finding—which begs for further research. Comparative trials, say, between the same therapy done according to a manual and without one. Because that finding could easily be due to the effects of other, confounding variables that have not been controlled for, and the only way to know with confidence that it's not artefactual is to test the hypothesis directly. On the other hand, cherry-picking the pieces of evidence you like from controlled quantitative research while disregarding other findings is just not kosher. Of course, that doesn't mean it isn't done; there are certainly people in (and out of) academia who make arguments of convenience and abandon them as soon as they no longer serve their purposes. Recently, a large controlled study here in the US tested whether intercessory prayer resulted in better outcomes for heart patients compared with no intercessory prayer. The investigators found that not only did prayer not result in better outcomes, but that those who knew they were being prayed for had MORE complications than the other two groups to whom they were being compared. Did the defenders of the faith accept this result? Of course not; they immediately began making various arguments to undermine the validity of the findings. Which is why doing studies like this is a colossal waste of time and money: no amount of scientific evidence is ever going to convince religious people that that prayer doesn't work, because they hold these beliefs as a matter of faith, and don't accept the purview of science over that domain.
As David's comments on psychoanalysis imply, the psychoanalytic community has borne more than a passing resemblance to other communities of faith, and this is a large part of the reason that it is dying here in the US (unlike our general population, academics here tend to look askance at those who can present no reliable evidence for what they are being asked to believe). I find it pleasingly ironic to see how closely the post-modern / post-structural community, seemingly at the opposite pole from the true believers, falls into the same patterns: if it supports our position we cite it; if it does not, we criticize the truth-claims of the research methods used to find it. On the other hand, those who are committed to science say: trust the data; it will teach you what you need to know. And this is why, for all its flaws, science remains the best game in town.
Tullio Carere, 17 Aprile 2006
Allan,
I proposed the bridge game metaphor in order to illustrate the idea that living systems don't work according to programs, but are constructions based on many levels of complex and hardly predictable events. You pick up my metaphor to suggest that in science, like in bridge, one has to play by the same rules as all other players (implying that I don't). Let me remind you, to begin with, what Paul Wachtel wrote in this forum on January 22: "scientific methods (plural) are that quite considerable variety of ways in which we try to minimize or reduce those effects" (i.e., the effects of self deception). Unless you consider Paul a suspect post-modernist, you could trust him (and myself) and admit that science is not a monolith, but a considerable variety of ways in which we try to reduce the effects of self deception - and each way has its own rules, pros and cons. Controlled quantitative research is just one of these ways. But let us limit our discussion to this one.
You say that "cherry-picking the pieces of evidence you like from controlled quantitative research while disregarding other findings is just not kosher". Which are the findings that I disregard? RCT are based on the hypothesis that one can dismantle or isolate "active ingredients" of psychotherapy and prove their efficacy on some disorders in some patients. I don't disregard the findings of this type of research. You can create a protocolized treatment and demonstrate that it works in the conditions of the experiment. I don't deny that you can. But your findings are really useful only if you can prove that (1) your experimental research has external validity, and (2) your protocolized treatment works better than a treatment using the same theoretical and technical tools in a non protocolized mode. It is no surprise to me that the external validity of RCT is very low, because living systems are much more complex and unpredictable than imagined by those who try to squeeze them on the Procrustean beds of protocols. By the same token, the results of Hettema's meta-analysis are no surprise.
On the other hand, research might demonstrate that some protocolized method works better than other non protocolized methods to obtain some results in some real, non experimental setting. Why not? This could happen. There could exist relatively simple situations, in which a desired result (say, the improvement of a symptom) can be obtained more rapidly and effectively following a protocol. I would not disregard such findings either, which implies that I could use that protocol in case my patient and I agreed that the improvement of that symptom is desirable per se, regardless of its meaning in the general economy of the patient's life. But this means that I would unlikely ever use that protocol, because I never try to target a symptom independently of its meaning in the patient's history and relationships. I do use procedures that the clinical experience has shown useful to treat some conditions, but I use them in a very flexible way, because I want to take into account the many variables of the patient's life, of my relationship with him or her, of his or her relationships with his or her significant others, and so on. The consequence of it is that I always apply a procedure in a heuristic, not in a protocolized mode.
More on that in my reply to David Allen.
Tullio Carere, 17 Aprile 2006
David Allen wrote:
> What I'm proposing is a different type of manual than the ones currently
> used in "empirically supported treatments." I don't disagree with your
> characterization of how a good therapist proceeds, nor with the importance
> of process research. However, process research can only tell us what
> sequence of interventions and responses probably led to a certain outcome in
> one patient. As you imply, the very same sequence in a similar-appearing
> patient might lead to quite a different outcome. I also agree that
> following a manual of cookbook interventions, rather than a manual
> consisting of a list of possible strategies for how to play out the bridge
> game you're talking about, does not approximate what a good therapist
> actually does.
I am happy that we agree on so many things.
> While the bridge player has a selection of cards to play,
> however, the selection is nonetheless limited to the cards in the player's
> hand. Therapist's possible responses are likewise numerous but nonetheless
> limited in numbe r by the theoretical perspective the therapist employs. I
> believe that all good therapists choose different arrows from their quivers
> based on a theory, whether they are able to articulate the theory or not.
> Otherwise the therapy would be chaotic.
Therapy *is* more chaotic than most of us would be willing to admit. The arrows therapists have in their quivers are usually not based on one theory, but on a mixture of a home theory, different theories assimilated on that base, and more theories not even assimilated, but just hanging around in a more or less eclectic way. Psychoanalysts have a word, "parameters", to collect all those things that they should not do, were they true to their home theory, but they nonetheless do to come out of the many impasses in which they wind up because of the inadequacy of their theories.
>In order to know what strategies are the
> most likely to succeed with a patient who is responding to interventions in
> a particular way, one has to look at collective data on therapies employing
> the various strategies. The plural of anecdote is indeed data, if the
> anecdotes are collected in a somewhat rigorous way. The measurements,
> because human behavior is so complex, will of course be far less precise
> than those in a physics experiment, but I don't think that means we should
> abandon the effort to look at therapy from the collective rather than the
> individual vantage point.
Surely, the collective vantage point is absolutely necessary. But how are collective data collected? Speaking for myself, I have been helped so many times by accurate and rigorous descriptions of clinical cases, but don't remember one single occasion in which I have been helped in my everyday practice by quantitative measurement and statistic elaborations.
>In a manual I've devised for my model for treating patients with self
> destructive personality traits, Unified Therapy, I try to define the primary
> goals for each stage of therapy (for example, getting a "borderline" patient
> to accurately describe certain repetitive ongoing interactions with members
> of his or her family of origin that serve as triggers for the patient's
> problematic behavior). These goals can be achieved using a fairly wide
> variety of strategies, any one of which can (and must, if the therapist is
> sticking to the manual) make sense within the confines of my theory. If the
> desired results (getting the detailed descriptions of the interactions, in
> this case), do not occur, the therapist must try a different strategy, and
> keep altering the strategy as needed, based on the responses of the patient,
> until the goal is achieved. In order to adhere to the manual, this is the
> sort of flexible approach the therapist must employ.
The crucial question, in my view, is: Is your ground knowing or unknowing? If your ground is knowing, (1) you know that therapy can be divided into stages; (2) you know how to detect which stage you are in; (3) you know which are the primary goals of each stage; (4) you know which are the best strategies to address those goals; etcetera. You know much too much for my taste (if I put myself in the shoes of your patient). But if, as I hope, your ground is unknowing, you don't know a nothing for certain, but your or your colleagues' experience tells you that *sometimes* therapy can be divided into stages; you can *try to guess* which stage you are in; there is some *undefined possibility* that the goals of your patient in this stage *bear some resemblance* with the goals of other patients in the same stage; there is again some *undefined possibility* that some strategies that have worked with other patients will work with this patient too; etcetera.
If you are an unknower I am sure that your manual will be useful to you and possibly others to orient yourself or themselves in the relationship with these difficult patients. And, by the way, a warm welcome to the network of the unknowers.
>Of course, getting an outcome study funded to see if this works is a whole
> different issue!
This is what the knower in you is interested in. I hope that the unknower will wipe this idea out of your mind. Outcome studies make the Dodo bird very happy, but apart from this I can't see any relevant contribution to the science of psychotherapy coming from that side so far. Science, as I see it, is based on unknowing, not on knowing. As Paul pointed out, science is there to help us fight self deception. As Socrates pointed out, the very idea of knowing something is at the core of self deception. Psychotherapeutic science is not about administering empirically validated procedures to our patients. As professionals, we are bound to be as knowledgeable as possible about the most frequent patterns in our field, not unlike good bridge players. But then, we should start the session with a blank mind, free from preconceptions and expectations, completely open to the mystery of every human encounter. In this regard the therapist is a mystic. Yet he or she is also a scientist, always suspicious of all mysteries. This is why he or she should produce objective material, as I often have emphasized (like recordings, questionnaires, written material by both the therapist and the patient), to document the process and allow for a comparison between different vantage points (the therapist's, the patient's, outside observers').
True science happens, in my view, when the mystic and the scientist have a good working relationship. When the scientist bullies the mystic the drift towards scientism is almost inevitable.
David Allen, 18 Aprile 2006
Tullio you wrote:
<<Therapy *is* more chaotic than most of us would be willing to admit. The arrows therapists have in their quivers are usually not based on one theory, but on a mixture of a home theory, different theories assimilated on that base, and more theories not even assimilated, but just hanging around in a more or less eclectic way. Psychoanalysts have a word, "parameters", to collect all those things that they should not do, were they true to their home theory, but they nonetheless do to come out of the many impasses in which they wind up because of the inadequacy of their theories.>>
Therapy is partially controlled chaos. One can use techniques that come from other therapies, as Arnold Lazarus has pointed out, without necessarily subscribing to the theory that spawned them. I believe that a good therapist borrows a technique based on its applicability to their own theory about what works with patients to achieve a certain goal in therapy. There is always more than one way to achieve the same goal within a therapist's theoretical parameters. (If analysts exclude certain parameters altogether, maybe that's a scientific error; perhaps those parameters should be included, at least under some circumstances. Their strictures against ever including spouses and family members in the therapy of their patients are just plain counterproductive). While the goal of therapy may change somewhat as new information arises in therapy, I believe that the overall goal of therapy is quite specific: to help patients to solve the problem they came in with, not just to explore their psyches in an open-ended fashion.
<< Surely, the collective vantage point is absolutely necessary. But how are collective data collected? Speaking for myself, I have been helped so many times by accurate and rigorous descriptions of clinical cases, but don't remember one single occasion in which I have been helped in my everyday practice by quantitative measurement and statistic elaborations.>>
I like you have not found much help in quantitative studies produced thus far either, and if the complaints by psychotherapy researchers that clinicians ignore their findings are any indication, we are not alone in this. However, that's more a commentary on the sad state of current psychotherapy research rather than an argument against using scientific and mathematical approaches to understand therapeutic change. Particularly irritating are those CBT researchers who make exaggerated claims for the efficacy of their approach while simultaneously ignoring the significant limitations of their studies and blocking those interested in researching other ideas from getting funding.
<<The crucial question, in my view, is: Is your ground knowing or unknowing? If your ground is knowing, (1) you know that therapy can be divided into stages; (2) you know how to detect which stage you are in; (3) you know which are the primary goals of each stage; (4) you know which are the best strategies to address those goals; etcetera. You know much too much for my taste (if I put myself in the shoes of your patient). But if, as I hope, your ground is unknowing, you don't know a nothing for certain, but your or your colleagues' experience tells you that *sometimes* therapy can be divided into stages; you can *try to guess* which stage you are in; there is some *undefined possibility* that the goals of your patient in this stage *bear some resemblance* with the goals of other patients in the same stage; there is again some *undefined possibility* that some strategies that have worked with other patients will work with this patient too; etcetera.
If you are an unknower I am sure that your manual will be useful to you and possibly others to orient yourself or themselves in the relationship with these difficult patients. And, by the way, a warm welcome to the network of the unknowers.
This is what the knower in you is interested in. I hope that the unknower will wipe this idea out of your mind. Outcome studies make the Dodo bird very happy, but apart from this I can't see any relevant contribution to the science of psychotherapy coming from that side so far. Science, as I see it, is based on unknowing, not on knowing. As Paul pointed out, science is there to help us fight self deception. As Socrates pointed out, the very idea of knowing something is at the core of self deception. Psychotherapeutic science is not about administering empirically validated procedures to our patients. As professionals, we are bound to be as knowledgeable as possible about the most frequent patterns in our field, not unlike good bridge players. But then, we should start the session with a blank mind, free from preconceptions and expectations, completely open to the mystery
of every human encounter. In this regard the therapist is a mystic. Yet he or she is also a scientist, always suspicious of all mysteries. This is why he or she should produce objective material, as I often have emphasized (like recordings, questionnaires, written material by both the therapist and the patient), to document the process and allow for a comparison between different vantage points (the therapist's, the patient's, outside observers').
True science happens, in my view, when the mystic and the scientist have a good working relationship. When the scientist bullies the mystic the drift towards scientism is almost inevitable.>>
Here we will have to agree to disagree completely. While certainly there is a lot about human behavior we don't understand, and more importantly because I do believe in free will, of course there's always a high degree of uncertainty in any part of any therapeutic endeavor. I have no problem acknowledging that I am an "unknower" about many things. When a patient first comes in, we know next to nothing. Nonetheless, I do think it is quite possible to come to know many things about our patients with a reasonable degree of certainty. Also, if I were a patient in emotional distress and wanted to talk to a mystic, I'd go to a priest or a shaman. If I went to a doctor, I would very appropriately expect that the doctor know more about human psychological functioning than I do. Otherwise, why would I pay him or her? And I certainly wouldn't want the rates on my health insurance policy to go up (a real problem in the US where there is no universal health care) because my insurance company pays for patients' mystical explorations. I totally reject Bion's admonitions that we do therapy with "no memory and no desire;" both of these things can be used for good or ill.
Tyler Carpenter, 20 Aprile 2006
Tullio,
I started to collect your responses, but wonder if you have written a book or would these responses be more suitable in an essay format? As a former research associate, on a biologically based programmatic medical school research team on psychosis, for a decade, as well as a long time
clinician with a commitment to psychotherapy integration, I find little to quibble with in your answers ('cept maybe a whiff of jaundice in your view of empirical research). A slender book of such essays to add to the shelf would be a treat and a wonder.
Tullio Carere, 21 Aprile 2006
Tyler,
thank you for your kind words. My current priority is to write a book (in Italian) on the "Care of
the self" as an ongoing, permanent commitment which may or may not include psychotherapy. If there were an American publisher interested in an English version of this book, I would be glad to edit it when the Italian text is ready (by the end of the year, I guess).
Tyler Carpenter, 21 Aprile 2006
Please let me know when you finish your book and start shopping for an English publisher. Though my Latin was never good enough to give me the faintest hope of transforming it into a journeyman's grasp of Italian (trying to recapture and evolve the real trombone skills of my youth is a daunting enough prospect!), I would love to keep abreast of the book's progress and eventually be able to read it.
As for fighting the medicalization of psychotherapy, to the extent that such a movement has enduring substance (other than in our mind's eye or the professional bodies politic), I'm more against the "ization" of anything and what such things negatively imply in terms of reductionism and control, than against the integration of multiple levels of systemic knowledge in the service of real therapeutics. I suspect that based on things you have said in the past regarding the way in which you employ adjunctive psychopharmacotherapy in treatment, we are of much more similar mind than may be manifested in our words. I can't imagine that you would employ agents that were not empirically and scientifically developed and which you are free to utilize in order to practice the fine art of psychotherapy with more difficult patients. Similarly, results of some studies often provide evidence of active elements we can transform usefully in a more integrative treatment.
Unfortunately, we are no closer to being able to sensibly articulate the practical alchemy of good psychological treatment than is a fine jazz quartet able to say what it does to find its groove and connect with an audience. At best, I think, a truly multi-disciplinary discussion of the applied epistemology of a multi-system approach to psychological treatment remains at the level of a graduate student discussion.
I do believe, however, it is extraordinarily difficult at times for experienced 'local-scientists' to adopt the unknowing stance of their therapeutic work in the service of really complex discussions of the art and science of treatment. The consulting room, for my money, is really primarily in our minds and a lot larger place than our discussions of the relevant concepts would lead the casual observer to suspect.
Tullio Carere, 21 Aprile 2006
David Allen wrote:
> While the goal of therapy may change somewhat as new information arises in therapy, I believe
> that the overall goal of therapy is quite specific: to help patients to solve the problem they came >in with, not just to explore their psyches in an open-ended fashion.
David,
in my view, as you may remember, there are basically two kinds of therapists: those who are procedure oriented (pd.o), and those who are process oriented (ps.o). The pd.os want to help their patients solve the problem they came in with, your definition is perfect. The pd.os are typically knowers. They know (well enough) that their patients' problem is the one they came in with. Consequently, they employ the more empirically supported procedures available to solve that problem. No room for 'mystical explorations' here. The ps.os, on the contrary, are typically unknowers. They don't know if the problem the patients came in with is their real problem, nor the one they really need or want to solve. Therefore a little exploration is mandatory, to begin with. As a result, it is very likely that the problem will appear in a new light, more complex, with more facets than it had in the beginning. Nevertheless, after the initial exploration the ps.o therapist can be persuaded that the help the patient needs right now is in fact to solve the problem he came in with. In that case, the ps.o therapist will organize the therapy around this focus (following Thomae and Kaechele, ps.o therapy can be defined as "an ongoing, temporally unlimited focal therapy with a changing focus"). The difference between the two therapies is that in the pd.o the focus is at least relatively fixed, and so is the procedure to work on it, whereas in the ps.o the focus is ever changing (even from one session to the next, even within the same session), and so are the ways to meet the different needs that unpredictably turn up in the process. In the former the exploration is limited to the initial sessions or non existent at all, in the latter the exploration is ongoing along the whole therapy.
In my view it would be exciting if the two styles of work could freely compete in the market. For instance, an insurance company could provide a psychotherapy module of X sessions repeatable Y times if the therapist can produce documentation proving that (a) at the end of each module there is a result in terms of symptom reduction and/or improvement of the quality of life, and (b) the result can be reasonably ascribed to the therapy itself (i.e., there is a process-outcome correlation). Of course no insurance company would cover the cost of an open-ended therapy. It means that after Y modules of successful therapy, the patient would have to choose whether to stop there, or to go on at his or her own expenses.
David Allen, 21 Aprile 2006
Tullio
We're not too far apart on what you are saying here. I guess I am what you call a procedure-oriented therapist, but not at the beginning of treatment. At the beginning, I am quite process oriented. Even some of us medical model types in psychotherapy know that the patient's initial chief complaint may be the proverbial tip of the iceberg, or may be tangential to a more basic problem that would need to be addressed before the presenting problem could be solved. An open exploration of the patient's thoughts and feelings is in my opinion a necessity for formulating clinical goals. Not only may larger, more central problems be revealed this way, but essential details may not be revealed at all to the therapist until patients develop a trusting relationship with the therapist. Open exploration with an empathic therapist allows patients to develop the necessary trust to reveal parts of themselves and their families that they do not find acceptable, or for which they expect condemnation from their social system. Without these details, the therapist may be unknowingly tilting at windmills.
Since I am more of what you call procedure oriented than you, however, once the more basic problem is clearly identified, my goal is, at that stage of therapy, first and formost to solve it. If new information unpredictably arises later in treatment that alters the clinical picture, my case formulation of course would then have to change. I still believe that at some point, the therapist has to draw some sort of preliminary conclusion about the nature of the prime issues with which the patient is struggling.
I also did not mean to come across as condemning therapists who are interested in an open exploration of a client's psyche if that is what the client wants. I don't see a problem with it as long as clients are, as you say, doing so at their own expense.
George Stricker, 22 Aprile 2006
I agree with you David. I've found that patients often will come in with genuinely concerning basic problems (not code for issues we have more fun with), and they deserve procedure oriented attention to those problems. However, having done so, they then often are willing, in the context of the success and solid alliance that has been established, to move to a more process oriented exploration of the issues that got them there in the first place.
Chris Wagner, 22 April 2006
Hi Tullio,
Wouldn't one of the ideas of psychotherapy integration be that therapists could synthesise the procedural and process styles? I don't really find myself subscribing entirely to either model. It seems possible to start out trying to help a client solve the problem he/she came in with and then be
flexible enough to transition to other concerns/issues as indicated. Therapist and client can hit the ground running and make progress in the very first session, which may be the only time the therapist ever sees the client. This show of respect for the client (honouring the request they come
in the door instead of mandating initial exploration of other issues) and demonstration of ability to move forward immediately can boost the client's confidence to share deeper, more painful, and more vulnerable concerns, and begin to help the client discover how issues may be connected.
In one of my favourite video demonstrations of motivational interviewing, within two minutes the therapist (Bill Miller) says to the client:" How might you like things to be different? I guess that's a good place to start." To me, this is a great example of how someone can be future-focused in such a way that some of the inefficiencies of process-oriented exploration are avoided. From the outset, problems are identified only as barriers to where the client wants to go, and momentum toward greater satisfaction is begun immediately.
Tullio Carere, 23 Aprile 2006
David, George, Chris:
As I wrote you a couple of weeks ago, I returned from the Florence SEPI Conference 'healed' from the dichotomy (please forgive myself-quotation) "that seemed to me necessary to house two radically different and incompatible souls in one conference. I was healed because I learnt, to my relief, that an empirically supported psychotherapy hardly exists in the real world of psychotherapy, as represented at the conference by the twenty plus speakers of all theoretical persuasions".
The key word, in my healing, was 'customization', specially emphasized by John Norcross. Let me make this point a little clearer. There obviously exist in our field both procedure and process oriented therapists of the 'pure' type. Examples of the former are those therapists that in very short treatments aim at formulating a diagnose and employing the corresponding procedure in a protocol mode; examples of the latter are the radical Bionian analysts, or those who consider the 'now moments' the only crucial events in psychotherapy. I surely am not a radical Bionian, to the extent that I use many useful procedures, but I never use them in any protocol mode. The protocol mode, on the other hand, is mandatory for those who want their work to be empirically supported, because the many modifications introduced to adapt to procedure to the patient's needs, the therapist's personality, and the specific context of the session, result in something that bears only a pale resemblance to the original, protocolized thing, for which any claims of being empirically supported are inappropriate.
Once the protocol mode of working is left to those who need or appreciate it, and is no longer considered as a mandatory feature of a procedure, the ground for integration of procedure and process is set free. I still think that most of us are more procedure or more process oriented, but the relation between the two is basically the one between foreground and background. For instance, for a process oriented therapist like me the process is in the foreground and the procedure is in the background, but many times the relation is reversed and the procedure comes in the foreground. When the 'flow' is optimal, the integration is seamless and I can no longer tell what is process and what is procedure.
Allan Zuckoff, 25 Aprile 2006
Tullio wrote:
<<By the same token, the results of Hettema's meta-analysis are no surprise>>.
Tullio,
Though there have been many interesting issues at play in this discussion, I wish to focus rather narrowly on the one area where I feel we are most in conflict. My question is this: What if the Hettema et al (2005) meta-analysis had found that the effect size for manualized MI was almost twice that of that for non-manualized MI (rather than the other way around)? Would you accept this as evidence against your position? If the answer is yes, then I withdraw, with apologies, my accusation that you have been unwilling to play by the rules of the game. If the answer is no, then you will have to explain to me according to what rules of discourse it is legitimate to cite only those findings that seem to support one’s own position.
Tyler Carpenter, 25 Aprile 2006
Unfortunately, Allan, the way the game is played frequently is that studies that don't confirm ones position or are at odds with it are invalidated by attacks on methodology in the name of the scientific method (which is often narrowly understood and appealed to by those with limited experience in research). Less informed and experienced folks don't know what the real questions are, experienced folks don't spend much time at remedying the confusion unless invested in teaching others, and the really experienced and occasionally cynical play.
Allan Zuckoff, 25 Aprile 2006
Tyler,
I am well acquainted with the various, unsavory ways the game can be (and is) played in other settings. I have also been fortunate to see it played in ways that are beyond reproach. Before I continue to invest in this discussion, I would like to know how it’s being played here.
David Allen, 25 Aprile 2006
Tullio, you write :
<<.the many modifications introduced to adapt to procedure to the patient's needs, the therapist's personality, and the specific context of the session, result in something that bears only a pale resemblance to the original, protocolized thing, for which any claims of being empirically
supported are inappropriate. >>
Again, I disagree with this sort of either-or thinking. As long as a treatment manual allows flexibility, it need only be used to determine whether the modifications to the protocol you describe are consistent with a given treatment model or not. This sort of determination allows for a fairly wide range of interventions, which can therefore be tailored to the ongoing process. Obviously, one couldn't do therapy according to such a treatment manual in a way that was totally eclectic (i.e, the therapist being free to borrow techniques from a wide range of treatment models). Nonetheless it would still give some credence (but not proof) to the individual models from which the eclectic therapist borrows interventions.
Tyler Carpenter, 26 Aprile 2006
Seems to me that an earnest effort is being made to come to mutual understanding, Allan, though that doesn't always mean the goal will be achieved. I'm not sure about whether I'd really make reproach an element in my evaluation, especially since even in those areas and among those I suspect that you would label in a way suggesting that there was no reproach, there is plenty of bias and sturm und drang (as differentiated from smoke and mirrors). When I set out to learn about integration of therapies in the mid-70s there was much to learn and no absence of opinions and conflict, both within and among schools of thought. Though the interdisciplinary dialogue has become less hostile and more accommodating, there are still the limits to integration reflected in the ways in which the task is discussed. I don't think that is going away anytime soon. Perhaps when I hear studies cited as ways of knowing and not indications of the truth, I'll feel more optimistic. In any event there seems to be progress being made and no obvious ill intent. I'd continue to keep an eye on how things are framed, talked about, but I'd leave the reproach on the side.
Mark Dworkin, 26 Aprile 2006
Dear All:
I have been reading this discussion with great interest. One personal/professional observation has to do with the level of experience of the clinician. For example, senior clinicians who practice EMDR can do so relationally using clinical judgment to alter some of the procedures without compromising the method.
Chris Wagner, 27 Aprile 2006
Hi Tyler,
As Allan refers to Motivational Interviewing, I'd like to mention a few things about the community that surrounds it. Over the past 8 years especially, we've developed a very active community of researchers, clinicians and theorists from many professions, focused on many different population bases and settings, and across many cultures and languages. Of course there remains bias in our discussions, because we all share some basic viewpoints ( e.g., that consultations should be client-centered in nature, not therapist-centered). However, even around those core issues there is much discussion of divergences (e.g., when, where and how should interactions sometimes not be client-centered). There is sturm and drang, and confirmation bias, but it is a group in which members continue to challenge perspectives, assumptions, and methods (both research and clinical). The approach is thus growing in a way and at a pace that wouldn't have been possible before the internet. Bill Miller and Steve Rollnick initially developed the approach (packaging components of various theories, therapies and findings from social and cognitive psychology), and remain the most prominent communicators, but the continued growth of the approach is truly organic and based on hundreds of individuals' experiences and interpretations. It's exciting to be a part of, and I think shows one path where integration can occur - not so much between schools of thought as within. I believe this is a direction that may continue to flourish. For example, looking at the Acceptance and Commitment Therapy approach - it is based explicitly on Skinnerian behaviorism in which language is just another behavior, yet it couldn't exist without the contributions of humanistic (moving toward self-actualization), existential (meaning), gestalt (experiential paths to knowing) and other orientations. Perhaps trying to reconcile at a high level the various schools of therapy is less promising than looking for integration to take place within approaches. My own sense is that many newer approaches are integrative already, and that they may have outgrown the ability of the old containers of the traditional schools of thought to hold them anyway. They don't fit neatly in any one theoretical or tradition-based box.
In reply to your referring to studies as "ways of knowing" comment, let me see if this is the kind of thing you are talking about. The Hettema meta-analysis may reflect an issue that Bill Miller has spoken on several times at conferences, in a presentation titled "Wrong for the Right Reason." The essence is - we developed ideas that the approach should be interactive and based on moment-to-moment readiness of the client, then we tried to manualize procedures to fit the requirements of clinical trials, and we discovered through process research that our manualization interfered with the effectiveness of our work (at least in this one study). Using "change talk" as an indicator (client language that makes positive references toward making changes), the open sections of sessions increased client positivity toward change, and when therapists followed manualized procedures, clients reliably moved away from talking about change (perhaps not coincidentally producing a null outcome in this trial). I'm not entirely convinced that the Hettema meta-analysis is reflecting the same thing, but it is interesting to think about.
Tyler Carpenter, 28 Aprile 2006
I suspect we're on the same page, Chris. I'm currently reviewing Hal Arkowwitz' and David Engle's excellent book on working with ambivalence in treatment. To the extent that their discussion of an integration of motivational interviewing reflects the group you are talking about I absolutely understand your enthusiasm. In a way I envy your generation the access to the net to do the work. I travelled in my car a lot and slept on the front seat for a few hours after working nights before the conferences. A lot of times (prior to SEPI) groups didn't talk between one another and one was looked at as an apostate for thinking integratively. When I began my interest in integration in the 70's it was a lot lonelier and would have been easier to contact people over the virtual world via computer. However, the sense of adventure and thrill was likely similar.
Tullio Carere, 28 Aprile 2006
Allan,
your question is important and I like you ask it. Yet, it is too complex a question to be exhausted by a plain yes or no. Let me make one premise. One of the rules of the game of the outcome studies is that the result of one study is not accepted as conclusive. If a positive correlation has been found between a given procedure and a therapeutic outcome, this result has to be replicated by independent researchers before it can be accepted as valid. Hence the importance of meta-analyses, like the one you quoted. However, if the results of a meta-analysis don't support one's position, what regularly happens is that these results are "invalidated by attacks on methodology in the name of the scientific method", as Tyler fittingly wrote. This is what happened in the case of Hettema's meta-analysis, and more importantly in the case of all meta-analyses that have shown a low, hardly significant effect-size of all sorts of specific procedures ("the Dodo bird verdict"). This prompted Luborsky et al to bring the analysis of outcome studies to an even higher level, namely that of the mega-analysis (meta-analysis of meta-analyses). "The Dodo bird is alive and well", was Luborsky's et al (2002) conclusion, which not unexpectedly failed to impress those who hate that bird.
How come that the rules of the game of the outcome studies are regularly broken by the very people who believe these studies to be the highest expression of science applied to psychotherapy, when they don't support their positions? Contemporary epistemology has an answer: All scientific enterprise is based on some metaphysical presuppositions, which researchers are mostly unaware of. As a consequence, when the data don't fit the beliefs, one is liable to blame the data or the method, rather than question their beliefs. It seems to me that most empirical research is done on the tacit belief that science operates on quantitative, measurable data, rather than on complex, hardly quantifiable phenomena. They conceive science as a way to make things simpler, protocolized and measurable, and when their efforts fail they are at a loss.
My (metaphysical) position is that life is much more complex than an approach based on linear causality can describe, but I believe that in this complex world some phenomena are in some respect relatively simpler and more predictable (as for instance the effects of the prescription of a drug). Therefore, I could admit that someone has invented a psychotherapeutic procedure that can be prescribed more or less like a drug without having to change my position. When I prescribe a medicine, in fact, I follow some guidelines derived from both clinical experience and RCTs. However, as I explained previously, even in drug prescription the protocol plays a minor role in my
therapies, where the major role is played by the exploration of the meaning that all events, drug prescription included, unpredictably generate in the mind of both patient and therapist (or in the field created by the two). Not for the sake of exploration per se, but because I find much more rewarding to be guided by the understanding of whatever happens moment by moment in the process than by any manual, were it written by God him or herself in the Bible or the Coran.
In my world view things are complex, but sometimes they can be usefully simplified. Sometimes things are so complex, that a manualized mode could be more effective than a non manualized one. In principle it is possible (above all for less experienced therapists, I believe). Therefore, if the Hettema et al meta-analysis had found that the effect size for manualized MI was almost twice of that for non-manualized MI rather than the other way around, I could accept this without having to change my position. I would be a little surprised, but not at all upset.
Tullio Carere, 29 Aprile 2006
David,
we should try to better understand what flexibility, applied to a manual, means. For instance, the Catholic Church has its own manual of behavior called catechism. They say that it has a fair degree of flexibility (nobody likes to be called rigid), inasmuch as the manual foresees many different responses to different situations. This allows for a fairly wide range of behaviors, which can therefore be tailored to the ongoing situation (I have paraphrased your words). The believers in this manual, therefore, will always say that it allows a flexible and sensitive approach to the many different conditions of life. But what if the believer's evaluation of a given situation makes him or her think that the best response is one that is not foreseen, or is explicitly forbidden by the manual? In case of conflict the believer must follow the guide of the manual, not of their conscience (otherwise they are no longer faithful members of that church/school).
Let me distinguish two different positions. In the former, which I would call the position of the believer, the therapist follows the guide of a manual in all fairness, at their best (and of course with all the flexibility that the manual foresees and allows). In the second, which I call the position of the layman ( "laico" in Italian, but I am not sure of the best English translation of this word), the therapist can employ not just a manual, but many manuals for a first or a general orientation, but in case of conflict between different manuals, and above all between a manual and their own evaluation, the decision will always be made according to one's own conscience, not to the conscience of somebody else as embodied in a manual.
I hope this helps clarify my position, which is not against manuals, but against the clerical use of them. Especially by the followers of the most successful religion today in the western world, that is scientism. The authority of charismatic revelations and dogmatic institutions is replaced, in scientism, by the authority of scientific research. But whereas the followers of traditional religions are mostly aware of their dogmatic foundations, the followers of scientism mostly are not. They believe scientific research to be neutral, that is free of metaphysical presupposition, which is not. Hence their blind faith in whatever can be protocolized and measured. But, of course, science is another thing.