Dibattito postcongressuale
2° CONGRESSO S.E.P.I. ITALIA Firenze 24-26 Marzo 2006
Pagina 1 >>
Tyler Carpenter, 30 Aprile 2006
Delightful, Tullio, I just made a folder with your name on it until I get an English translation of the book!
Tullio Carere, 30 Aprile 2006
The provisional title of the book is "Lo spirito laico e la cura di sé" (The lay spirit and the care of the self). In view of the English translation, I wonder if 'lay' fittingly translates 'laico'. The 'lay' spirit is the spirit of those who give up all dogmas, both of old and new religions, both of spiritualism and materialism, and have their conscience (in dialogue with other consciences) as the only guide. But ordinary conscience is not too reliable a guide, conditioned as it is by so many biological, economic, social, and cultural factors. It implies that a genuinely lay position cannot be separated from a full take of responsibility of freeing, waking up, enlightening one's own consciousness/conscience. This is what "care of the self" means, an ongoing, lifelong commitment to working on oneself, which may include, but not necessarily, a psychotherapy.
The theme of 'laity' is specially felt in Latin countries, where the presence of the Catholic Church is specially strong. I wonder how the theme is dealt with in the Anglo-saxon area. (Hilde, are you reading me? I hope to hear from you soon, after your last trials).
Thanks to all who will want to enlighten me.
Tyler Carpenter, 1 Maggio 2006
I toyed with the title, "Finding your own way." myself, but have something else to write first. Sounds like your book will have a wide audience. Strangely enough, it is just such thinking that I believe allows us to get by with the more managed care brief approaches. When one understands what supports and fosters change, there is much more to work with. A senior mentor once recommended, on hearing how I was beginning to work, looking into the psychoanalytic work pioneered during WWII and referred to as "Sector Therapy" whereby one focused on circumscribed character issues to induce change and manage symptoms.
Mardi Horowitz, 1 Maggio 2006
An interesting side light to the manual issue is the upcoming political ones. In psychiatry, psychodynamic and CBT competencies are both going to be necessary to pass the American boards in the near future. The tension between psychiatrists and psychologists on prescribing/therapizing will promote that phrase as a club: empirically based treatments. And then, psychologists versus master's level therapists (e.g. marriage and family) will come up as to who is licensed to make diagnoses and treatment plans. Since we will be less divisive in SEPI the debates on who does what to whom, and for how much, and why, will at least be amiable, wise, and rational.
Tyler Carpenter, 1 Maggio 2006
The sad part of it is, Mardi, that what is being credentialed should be no more than a transitional object on the way to more comprehensive understanding; and, the issue of prescription privileges for psychologists to assist the public sector need is a bit of a red herring. As any one with any depth and breadth of experience in public sector work knows most of the cases have multiple comorbid psychiatric and medical problems that raise not only diagnostic, but treatment and drug interaction issues that in bulk would challenge a good psychiatrist, let alone a prescription certified psychologist. I agree the "debate" in SEPI will be more civilized in no small matter because I suspect the issues involved are better understood.
Allan Zuckoff, 1 Maggio 2006
Tullio,
I respect your willingness to take up my challenge, and appreciate the thought you have put in to responding to it. I hope I can show the same respect by taking your response as seriously as you have taken mine.
First, I must correct your characterization of the findings of the Hettema et al. meta-analysis, which do not in fact support the dodo bird verdict. A main finding is that, even when compared with other active treatments, MI leads to significantly (reliably) better outcomes—the size of the effect varying between problem domains from small to large. Another, fascinating finding is that, when offered as a stand-alone intervention, the effects of MI (like those of almost every other form of therapy) diminish over time—but, in contrast, the advantage of adding MI to other, more intensive forms of therapy does not fade, but is maintained throughout all available follow-up points. When you also factor in the fact that in almost every case, the interventions MI is being tested against are more time-intensive (and expensive), the meta-analysis strongly supports the general efficacy of MI. At the same time, the intriguing finding that non-manualized instantiations of MI showed larger effects than manualized versions—which may well be explained, as David Allen would predict, by a failure of the manuals to build in flexibility in their use (or as Chris Wagner suggested, by their failure to hew to the spirit, rather than merely the techniques, of MI)—this finding requires replication via direct experimental tests.
On the other hand, on the importance of replication of results generally, and of meta-analysis specifically, we are in full agreement. We also agree that it will not do to demand empirical support for treatments… right up until the moment one’s own favored treatment is not supported. The community that has grown up around motivational interviewing, described by Chris Wagner, tends to take a dim view of such shenanigans, which you rightfully criticize—the tone was set for us by Bill Miller, who started out testing behavioral treatments for problem drinking and was directed by his data to question his assumption that it was the specific skills being taught that were having the effects he found. However, I have certainly witnessed the behavior you and Tyler describe—most often from proponents of cognitive-behavioral treatments. (I suspect that this is because CBTs have been most extensively tested—and that wider testing of other approaches will result in similar behavior from some of their proponents as well.) Dismaying as it is, I do not find such hypocrisy surprising; we are all loath to give up whatever we are invested in, even in the face of evidence to the contrary.
Which is exactly why science is so important, and why we must never confuse it with the behavior of individual scientists. (As Nietzsche taught us, the adherents of a philosophy are no argument against it.) Because, like you, I do not believe that linear causality can capture the full complexity of human being, I define science as encompassing qualitative as well as quantitative data—and I believe that they ought to be equal partners in the psychotherapy research enterprise. But I also believe, passionately, that far too often, self-indulgence has substituted for sound judgment among practicing psychotherapists as much as among psychotherapy researchers. And this was the primary source of my challenge to you: are you, too, willing to be convinced by the data, whatever they show?
And here, finally, your answer seems to come down to this:
<<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.>>
I can only understand this statement in two ways. You might mean that you find it personally more rewarding to work in this way—in which case, the only possible response I can think of is: So what? Our responsibility is to find out what works best, and to do it, our personal satisfaction in working that way be damned. Or you might mean that you believe working this way to be more effective, which only begs the question: Based on what? I assume, from your recent posts, that your answer would be: The individual conscience, well-disciplined and well-developed. But I’m afraid that I can find precious little evidence of any kind for your faith in the determinative capacity of this rare bird.
Whichever way you intended this statement, I believe that your underlying message is: I could accept a scientific outcome that conflicts with my beliefs, because I put little faith in science to discover anything more than trivial truths in this domain. And I’m afraid that I can only see your equation of a scientific approach to understanding psychotherapy effects with “scientism,” and your allusions to an identity between religious dogma and acceptance of scientific principles and methodology, as familiar tricks of the post-modernist whose will to power demands that he not cede supremacy to ways of knowing outside his purview—which, as I (with Nietzsche) see it, is where the real parallel to religious faith lies. As for me, until someone comes up with a better way of separating the wheat from the chaff, and of determining what is true and what is false, than through scientific methods (again, broadly defined), I would say that conscience demands that we look to those methods to learn how we ought to proceed.
Gerald Davison, 1 Maggio 2006
SEPI Colleagues,
It occurs to me that there may be interest in my first pres. column in The Clinical Psychologist, the newsletter of the Society of Clinical Psychology (Division 12 of APA). The URL is:
http://www.apa.org/divisions/div12/homepage.html
Tullio Carere, 1 Maggio 2006
Allan,
I am glad you agree that linear causality cannot capture the full complexity of human being, and science must encompass qualitative as well as quantitative data. However, we disagree on the relative importance of the two kinds of data. To me, they could not be equal partners in all sciences. In physics quantitative data are much more important than the qualitative ones, in psychotherapy the opposite is true. This is why I wrote that “I find much more rewarding to be guided by the understanding of whatever happens moment by moment in the process than by any manual”: these data are to me much more relevant than those obtained through RCTs. Anyway, whatever the respective proportion of the two types of data, it seems to me that my position is in line with the recommendations of the EBPP (Evidence-Based Practice in Psychology) Task Force Report, as quoted by Jerry Davison (thank you Jerry): the report suggests that clinicians must create “optimal combinations” of different kinds of research, their own individual personality and values, the treatment relationship, and the particularities of the patient to devise the best intervention. In my view, it is only to the extent that one is attuned to what happens moment by moment in the process that one can find the “optimal combination” of a huge array of factors. (In Jerry’s opinion the right intervention can only be right in the perspective of a given theory. In my opinion a theory capable of accounting for so many disparate and incommensurable data, both subjective and objective, both experiential and experimental, does not and cannot exist. But I’ll return to this very important question in a next posting).
You ask me to clarify what I mean by the word ‘rewarding’. Firstly, the attunement to what happens moment by moment is personally more rewarding. There is much research (Frank, Wampold) showing that the degree of satisfaction of the therapists with their own approach is highly correlated with the therapy outcome (some even suggest that this factor is the most highly correlated with the outcome of all). This is why I believe that nothing is wrong with your protocolized approaches, as long as you like them. Secondly, I cannot see how I could ever find the optimal combination of so many process and procedural factors, were I not attuned to whatever happens moment by moment in the session. Do you believe that the search for the optimal combination is not science? Do you believe that the EBPP Task Force is fostering a non scientific attitude? If you believe this, you might be right. The openness to whatever happens might have more to do with mystics, than with science. But, as I have repeatedly said, to be scientific in our field is not to administer procedures as if they were drugs, but (among other things) to be willing to produce documents of our work, in the form of recordings or questionnaires and written notes by both patient and therapist, in order to correlate process and outcome.
Finally, you suspect that I “could accept a scientific outcome that conflicts with my beliefs, because I put little faith in science to discover anything more than trivial truths in this domain”. I tried to explain that, to the contrary, I could accept your hypothetical result right because it would not be in conflict with my beliefs. Anyway, I suspect that your idea of what is “science”, or “evidence” is much too narrow, compared for instance to Jerry’s:
The core meaning of the word “empirical”, a term that has always been part of the discourse of what we are now calling “evidence-based,” is “based on experience.” And here’s where Pandora’s box is opened. Whose experience are we talking about? Are reports from clinicians to be accorded the same epistemological respect as the conclusions drawn by researchers based on a randomized clinical trial?
The word ‘empirical’ is finally returning to its original meaning, that is “based on experience”. The next step, I believe, will be the acknowledgment that in our field experience is incommensurably more precious than experiment. But enough for now.
Tyler Carpenter, 2 Maggio 2006
Great response, Allan. The nagging association I can't shake is the fact that you sound more like you would be quoting Karl Popper, while it is Tullio who comes across like the more poetic Nietzsche.
Allan Zuckoff, 2 Maggio 2006
Tyler,
Thanks—I think. I must admit that I have a prosaic soul, and not a mystical bone in my body. But I was trained in existential-phenomenological psychology and did graduate work in Continental philosophy before that. I love Nietzsche, Kierkegaard, Freud (that grumpy old continental), Sartre (well, maybe not Sartre; it’s hard to love Sartre), and most especially Merleau-Ponty; I’ve been moved by Heidegger (the early writings), I’m fond of Foucault, and I even developed a little liking for Lacan. I came to quantitative psychology much later, and cannot say I love it—but I have learned to respect it, despite its flaws and limitations. Never resonated much with Popper, but since Merleau-Ponty has been accused of advocating a phenomenological positivism, I guess there must be some affinity. And isn’t that what integration is all about?
Tyler Carpenter, 2 Maggio 2006
You're welcome, I suspect. So now I'm really puzzled, Allan. I'm familiar with, though not conversant in, all the marvelous writers you cite. I can detect the basis for Tullio's orientation, but yours seems further from its roots. Though I sometimes wonder how my colleagues in the clinical realm thought about my thoughts on treatment while I was part of the biological schizophrenia research world for a decade. I agree that's what integration is about.
Allan Zuckoff, 2 Maggio 2006
Tullio,
I suspect it will not surprise you to learn that we understand the message of the EBPP report differently. But I fear trying the patience of the rest of the listserv, so I will join you in saying: enough for now.