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The Dodo Verdict

(SEPI Forum, 5-23 June 2000)

 

 

(Editor's Note) George Stricker had the good idea of forwarding to the SEPI list a contribution on another list by Larry Beutler, some key points of which are the ones that follow: "Scholarly reviews of research by those within the broadly based psychotherapy research perspective have long held that the psychotherapy relationship, patient variables, and other non-technical factors, are more highly related to outcome than the specific procedures and theoretical model employed by the therapist…The low percentage of variance contributed by differences in the model and procedure used has been the basis for the Do-do Bird verdict---all psychotherapies obtain essentially equivalent results, a finding that keeps being repeated in the preponderance of meta-analytic reviews… It is fair to conclude that the correlations between qualities of the therapeutic relationship and outcome are almost always higher than the relationship between type of therapy applied and outcome--i.e., the relationship accounts for more of the variance than what the therapist does from a theory of change perspective." This started a debate in which mainly two positions were confronted. In one, as represented by George Stricker, "The Do-do bird challenge is to find differential effectiveness and, by doing so, get beyond common factors as the basis of all therapeutic change." An alternative way would be not to get beyond common factors in search of differential effectiveness, but on the contrary to look right there for the basis of all therapeutic change. The debate highlighted that these two positions are not to be thought as mutually exclusive, but rather as complementary.

 

George Stricker, 5 June 2000

Larry Beutler published the following on another list to which I belong. For those who haven't seen it and are interested, it presents a very comprehensive and useful summary of a very important area that has been part of the SEPI debate many times. I am forwarding it with Larry's permission.

________________________________________________

Jeff Lohr has raised a very important question about the causal relationship between the therapeutic alliance and outcome of psychotherapy. Distilled, Jeff's comment connotes some concern with two issues: (1) that the "therapeutic relationship/alliance" is touted as being more strongly related to outcome than the specific things that a therapist does or the particular model of therapy used, and (2) that is is assumed that the therapeutic relationship/alliance is causally related to outcome. Jeff wonders about the empirical evidence for these two assumptions.

The assumption that the relationship is a more powerful contributor to therapeutic outcome than the procedures used by the therapist is a common assumption among those who identify themselves with "Psychotherapy Research" and this position is represented among the membership of SPR (the Society for Psychotherapy Research, International). Jeff's comment, and the responses to it, remind me, however, that there is a different perspective represented among those who largely identify themselves with a specific, usually behavioral tradition. These individuals may be inclined to be more closely affiliated with AABT than with SPR. The latter viewpoint was expressed reasonably well by Bill Follette who expressed a lack of confidence in the research on therapeutic alliance or relationship. He expressed the view that (1) the measurement of therapeutic alliance or relationship was confounded with outcomes, and (2) the role of enhancements to the therapeutic relationship could be understood as a process in which the therapist enhanced their reinforcing power.

In the hope of increasing dialogue on these points, across the perspectives that differentially characterize these different scholarly traditions, I'd like to summarize some of the reasons for the two assumptions that Jeff initially brought into relief and in the process to address, through available research, why Bill's analysis of the relationship as a reinforcement enhancer does not do justice to the complexity of the process.

First, let me point out that these two different traditions, what I will simplistically refer to as "the psychotherapy research" and "the behavioral analysis" traditions, often differ very widely in what they select and focus on as the predictor and independent variables in treatment research. Admitedly, this is a simplistic distinction because there are a lot of overlaps between them, and frequently there are people who keep their hats in both camps. But, there are also some very clear differences between them. I remember David Barlow, for example, at an APA meeting a year or so ago, pointing out that in the circles in which he travels, the idea of "non-specific" effects or the Do-Do Bird verdict (assumedly related to the supremacy of relationship factors over technique and model factors) were seldom mentioned. David's view, I suspect, would be shared by most of those who identify themselves with "behavioral research" more than "psychotherapy research". And, this view leads people, I suspect, to place great emphasis and faith in the techniques of intervention and the theoretical model from which it comes. It is from this tradition that RCT research makes the most sense and the common assumption is that there are specific treatments for specific disorders.

While the RCT tradition, and the model of specific diseases and specific treatments that underlie it, certainly is conducive to the effort to define Empirically Supported Treatments initiated by Dave Barlow through SSCP, psychotherapy researchers of the SPR tradition are more persuaded by the influence of variables beyond specific, theory-derived procedures (e.g., relationship, therapist characteristics, etc.). Hence, John Norcross's development of a task force that is complementary to the Division 12 effort and that is designed to identify "components of the empirically supported relationship" (Incidentally, I speak as a member of both the Division 12 and the Division 29 Task Forces).

David Barlow's experience is very different from mine and I suspect, from the experiences of many of those who work within a broadly based "psychotherapy research" tradition. The assumption of the pre-eminence of techniques and specifically of cognitive and behavioral techniques over these external variables, is one that is often disparaged by broadly based psychotherapy researchers. These latter researchers are concerned, in their research, with a wider range of contributing and correlating variables than those that derive from a given theory like either IPT or CT. Their concerns are reflected in the chapters on Therapist, Client, and Process variables in the HANDBOOK OF PSYCHOTHERAPY AND BEHAVIOR CHANGE (Bergin & Garfield, 4th Ed., 1994, Wiley). While they conduct and have widely contributed to RCT research studies, psychotherapy researchers of this ilk are also drawn to methodologies that allow the study of variables that cannot be randomly assigned, such as therapist relationship factors, patient and therapist predisposing variables, personalities, etc. Some of Ken Howard's naturalistic research as well as his articulated concerns with the problems of RCT methodlogies are widely and highly valued among this group of scholars, probably much more so than they are among those committed to a theory-specific, and more particularly, a behavior analysis tradition.

Scholarly reivews of research in this area by those within the broadly based psychotherapy research perspective have long held that the psychotherapy relationship, patient variables, and other non-technical factors, are more highly related to outcome than the specific procedures and theoretical model employed by the therapist. Lambert & Bergin (1978) expressed this view years ago, and it has not substantially changed (see Lambert, 1989; 1994; Lambert & Bergin, 1994; Lambert, et al, 1986). Lambert & Assay (1992) apportioned the percentage of variance attributed to various therapist, client, and treatment factors and reached the conclusion that client variables are most strongly associated with outcome, followed by the quality of the therapeutic relationship (therapeutic alliance, facilitative relationship, etc.). The use of specific procedures and models (e.g., CT, IPT, etc.) accounte for less than 10% of the total outcome in their analysis. This proportion was similar to that reported in meta-analyses by (Smith, Glass, & Miller, 1981; Shapiro & Shapiro, 1984). The low percentage of variance contributed by differences in the model and procedure used has, as you know, been the basis for the Do-Do Bird verdict---all psychotherapies obtain essentially equivalent results, a finding that keeps being repeated in the preponderance of meta-analytic reviews (see Wampold, et al, 1997). Thus, it is fair to conclude that the correlations between qualities of the therapeutic relationship and outcome are almost always higher than the relationship between type of therapy applied and outcome---i.e., the relationship accounts for more of the variance than what the therapist does from a theory of change perspective.

Now the evidence for a causal relationship between relationship and outcome is a little less clear as Jeff has pointed out. Before it can be addressed adequately, Bill's concerns with the measurement of therapeutic alliance must be addressed. He observed that some items in relationship questionnaires often ask the rater (patient or therapist or clinician) if the client's goals are being achieved or if they are pleased with the way things are going. There has been much written about this apparent confound, but four points can be made: First, there are many measures of the therapeutic alliance, by various names, many of which do not include this confound (see Greenberg & Pinsof, 1986) but results seem quite independent of the specific measure used. Second, these measures are highly intercorrelated, frequently to the point of approximating their own reliability indices (Tichenor & Hill, 1987; Salvio, et al, 1992). Third (and there are several studies of this, but I can't bring the specific references to mind, so I'll use our own data), it makes little difference whether the relationship items that seem to reflect outcomes are excluded from the scales or not. Recently we submitted a study of the sequence among three classes of predictors--patient variables, therapy procedures, and matching variables--on two outcomes (therapeutic alliance and symptomatic change), and subsequently, the causal chain when relationship was inserted as one of the predictors . We were critiqued because our measure of alliance (an independent observer rating on the HAQ) included five (5) items that were confounded with outcome. We eliminated these items and correlated the scales using part-whole correlations, obtaining correlations above .80, not bad for a scale that has interrater reliabilities that are much lower than this, often. We are now looking to see if the use of the non-contaminated scale changes the pattern of relationships obtained, but I doubt it.

Finally, when measured as part of the therapeutic relationship, questions about outcome are in the nature of asking the respondent to reflect back and assess the degree of their progress. This single point in time (retrospective) measure of "outcome" would never be accepted in today's climate as a measure of improvement. In fact, one of the major critiques of the CR study was that the authors measured outcomes only at the end of treatment. The problem is that when measured in this way, there is only a very low correlation of these ratings and pre-post measures (Beutler, Wakefield, & Williams, 1994; Beutler & Hamblin, 1986). To compensate, the CR authors developed a retrospective pre-post measure (a procedure that our group had recommended in 1981). I've recently seen a study, the reference to which I can't pull up, that suggested that even these scores did not correlate well with actual pre-post measurement. In fact, these retrospective measures only correlate well with current state, leading to the conclusion that they are measures of "satisfaction" not measures of improvement. Thus, it is highly unlikely that the use of such items seriously contaminates pre-post measures of outcome.

Assuming that I have dispatched the issue of contamination raised by Bill Follette for the moment, let us look at the evidence for a causal chain between patient variables, through treatment procedures and relationships, to outcome. That evidence is relatively sparse, but two lines do suggest a causal chain that links relationship quality to outcome. First is a plethora of studies that have used lagged correlations between early developed relationships and outcomes. In Vanderbilt I, Strupp observed that the therapeutic relationship as measured before the 10th session predicted distal outcomes (This was reported in an SPR presentation---I don't know the published reference) and this was consistent with the early findings of Luborsky in the Penn Psychotherapy Project, in which ratings at session #3 were quite higly predictive of distal outcomes, sometimes 2 years later (Luborsky et al, 1991). (Both Les Greenberg and Adam Horvath have confirmed these findings, I believe, though I don't have a specific reference). In the study that I mentioned in an earlier paragraph, we also looked at early alliance (first five sessions) and distal outcome, obtaining a value of .36 after the influence of initial patient variables and therapy procedures were factored out through MR procedures.

In a Structural Equation Modeling procedure that compared a simple relationship --> outcome versus relationship + patient + matching variables --> outcome model, we found that both models were consistent with the data, but that process variables added variation that was independent of the therapy procedures used (Beutler, Clarkin, & Bongar, 2000). As you know, SEM doesn't care about the temporal sequence of variables. That has to be built into the model. So, SEM could easily confirm that a given data set is consistent with the view that distal outcome produced an earlier measured relationship event, if the investigator was foolish enough to propose this model to test.

As a final point, consider the repeated observation that different therapies often are distinguished by a particular pattern of developing the therapeutic relationship (Rounsaville, et al, 1987). I will send, to those who are interested, a series of graphs from a current comparison of three types of psychotherapy in the course of the development of the therapeutic alliance. These graphs are from an RCT study of CT and two new therapies, one focused explicitly on trying to develop a therapeutic alliance that is devoid of patient resistance and the other that matches specific treatments to specific non-diagnostic qualities of the patient. To summarize, the growth of the relationship differs quite distinctively. This morning, I got back a components analysis of these differences. I don't have it all digested yet, but it is clear that a given HAQ score in the three different therapies is reflecting a very different experience for each, and that the pattern of components over time is very different from therapy to therapy. While the overall correlation between early alliance and distal outcome, and even follow-up, remains in the .30-.40 range, therapies are distinguished by what items load in the ratings of alliance and the pattern of development is very different from therapy to therapy.

If all a good relationship did was improve the therapist's reinforcing power, I would think that the NT (relationship-based) therapy would have been the best on symptom measures, since the alliance was best in this treatment, but this was not the case. CT and PT produced better effects on several indices in this sample of co-morbid stimulant dependent and depressed patients.

References

Bergin, A.E., & Lambert, M.J. (l978). The evaluation of psychotherapeutic outcomes. In S.L. Garfield & A.E. Bergin (Eds.), Handbook of psychotherapy and behavior change: An empirical analysis (pp. 139-190). New York: John Wiley.

Beutler, L. E., Clarkin, J. F., & Bongar, B. (2000). Guidelines for the systematic treatment of the depressed patient. New York: Oxford University Press.

Beutler, L.E., & Hamblin, D.L. (1986). Individual outcome measures of internal change: Methodological considerations. Journal of Consulting and Clinical Psychology, 54, 48-53. (special edition)

Greenberg, L.S., & Pinsof, W.M. (l986). The psychotherapeutic process: A research handbook. New York: Guilford.

Lambert, M. J. (1989). The individual therapist's contribution to psychotherapy process and outcome. Clinical Psychology Review, 9, 469-485.

Lambert, M. J. (1994). Use of psychological tests for outcome assessment. In. M. E. Maruish (Ed.) The use of psychological testing for treatment planning and outcome assessment. Hillsdale, NJ: Lawrence Erlbaum Associates, Publishers.

Lambert, M. J., & Bergin, A. E. (1994). The effectiveness of psychotherapy. In A. E. Bergin & S. L. Garfield (Eds.), Handbook of psychotherapy and behavior change (4th ed., pp. 143ˆ189). New York: Wiley.

Lambert, M. J., Shapiro, D. A., & Bergin, A. E. (1986). The effectiveness of psychotherapy. In S. L. Garfield & A. E. Bergin (Eds.) Handbook of psychotherapy and behavior change, 3rd ed. (pp. 157-211). New York: John Wiley and Sons.

Rounsaville, B. J., Chevron, E. S., Prusoff, B. A., Elkin, I., Imber, S., Sotsky, S., & Watkins, J. (1987). The relation between specific and general dimensions of the psychotherapy process in interpersonal psychotherapy of depression. Journal of Consulting and Clinical Psychology, 55, 379-384.

Salvio, M., Beutler, L. E., Engle, D., & Wood, J. M. (1992). The strength of therapeutic alliance in three treatments for depression. Psychotherapy Research, 2, 31-36.

Shapiro, D.A., & Shapiro, D. (l982). Meta-analysis of comparative therapy outcome studies: A replication and refinement. Psychological Bulletin, 92, 58l-604.

Smith, M. L. Glass, G. V., & Miller, T. I. (1980). The benefits of psychotherapy. Baltimore: The Johns Hopkins University Press.

Tichenor, V., & Hill, C. E. (1989). A comparison of six measures of working alliance. Psychotherapy, 26, 195-199.

Wampold, B. E., Mondin, G. W., Moody, M., Stich, F., Benson, K., & Ahn, H. (1997). A meta-analysis of outcome studies comparing bona fide psychotherapies: Empirically, "All must have prizes." Psychological Bulletin, 122, 203-215.

 

Tullio Carere, 12 June 2000

I realize that a taxonomic approach (a map of the common psychotherapy factors organized in a comprehensive whole) has not much sex appeal, but could at least the Do-Do Bird verdict (thank you George for reminding us of it) be a firm point of departure? If we assume, according to this virdict, a large supremacy of relationship factors over technique and model factors as predictive of change, we are faced with a most basic question: What makes a therapeutic relation out of an ordinary, every-day relation?

One first possible answer would be the following: Therapeutic factors are embedded in ordinary, every-day relations, and a therapeutic relation is one led by a therapist who (a) knows which are these basic factors, and (b) knows how to activate and employ them moment by moment in the relation with her client. One second possible answer would be instead: As what happens in ordinary relations is that everybody tries to impose his theory or world view onto the other (and so called therapists are no different in this respect), real therapy only begins when one suspends his theoretical and personal preconceptions and persuades the other to do the same--thanks to this suspension a space opens where negotiations, new experience and genuine search can happen.

The two answers are not, to me, mutually ewclusive (but the second comes first, and breaks the ground to the first). Any other responses to the Do-Do Bird challenge?

 

Alan Javel, 13 June 2000

Differences are indeed easier to see, probably because they are the most glaring. To understand the similarities, one would need to look very closely at technique. In my opinion, what we do, how we do it, and when we do it are the basic building blocks of any relationship, therapeutic ones included. I am always disturbed by the idea that my theoretical orientation, whatever it may be, may merely be window dressing, a small part of the actual business of the therapy which has been defined by my office environment, my verbalizations, and my silences.

 

Hilde Rapp, 13 June 2000

Alas, the dodo bird was rendered down to illuminate the dark nights of explorers of uncharted territories...

 

If it weren't for the differences in viewpoint between our two eyes, our picture of the world would be rather one dimensional.

 

Similarly, to my way of working, much of the power of psychotherapy derives from those aspects of our practice which are different from the ways in which odinary relating takes place. In my personal experience, meta-conversations are singularly unpopular among my loved ones, yet they are the deadlock breakers in my therapeutic work.

 

I have no trouble with enthuisiastic clebrations of 'vive la differe/ance' – bowing to Derrida slightly –but I suppose as a Sepi-ite I see my task more as endeavouring to understand differences, and to understand whether they are merely interesting, trivial or therapeutically significant – in the way of Clarkin and Frances' differential therapeutics. We are way off being able to map systematic differential applications of therapeutic techniques to distinct clinical populations with measurable different problems in ways which yield demonstrable solutions.  Even if none of these ways of describing our art, science and craft chimes well with particular value base which puts the clients meaning making in the centre, there still is a burden of proof on us within Sepi that we do more than  provide human understnding and the equivalent of pastoral care.

 

This is were I like the postmodern stance: a modest approach to mapping some differences which seem to us clinically important, intellectually non trivial, and at least describable if not measurable in some coherent and communicable way: to start with the particular, the human, the subtle small gestures of human relating – and where we feel bold enough to look for the larger social paterns that connect...

  

Sepi is to my mind about generating interesting hypotheses about change factors and other things, to find really interesting ways of talking about the complexities of the human condition, and to bandy together with our colleages in SPR to devise intelligent ways of finding out what we do well that helps clients to put their life back together and to get on better with others...

 

How about the phoenix verdict?

 

 

Michael Basseches, 13 June 2000

I must have missed or forgotten the original do-do bird challenge--Could you, George, or someone, remind me.

But to answer to the question Tullio poses would be to agree that "therapeutic factors are embedded in ordinary, every-day relations". I would add though that psychologically destructive factors are also embedded in ordinary every-day relations. Clients often come to us with a hope to remedy some of the damage that their relationships have done to them, or ways in which their development has been constrained by those relationships, but with a repertoire (of action/meaning-making schemes) that may provoke others to repeat the damage that has been done. Therefore, I view no goal as more important in therapist training than learning how to create relationships which minimize the destructive factors, as well as to optimize the therapeutic factors in "ordinary every-day relations". You refer to the latter when you say--"a therapeutic relation is one led by a therapist who (a) knows which are these basic factors, and (b) knows how to activate and employ them moment by moment in the relation with her client," but as you know from what I have written, I think the former dimension--effort and skill at avoiding harm or oppression (Leston Havens calls it "predation") is equally important.

Your second answer -- suspending theoretical and personal preconceptions -- may be one way of attempting to avoid harming clients within therapy relationships, but I have trouble endorsing that one because I think (as you do, I believe) that it is impossible to do so completely, and also, because there are many other skills required in this effort as well. Thank you for pushing/inviting us to keep addressing such crucial questions in the service of psychotherapy integration.

 

 

 

George Stricker, 14 June 2000

Dear Mike,

I'll just respond to your question to me, and reserve any other comments for another time. In the 1970s Luborsky wrote a summary of psychotherapy research, found overwhelming evidence for effectiveness, but no evidence for differential effectiveness among orientations. His article was subtitled "All have won and all must have prizes," from Alice in Wonderland, hence the term Do-do bird effect. The Do-do bird challenge is to find differential effectiveness and, by doing so, get beyond common factors as the basis of all therapeutic change. That is exactly what is being attempted by people such as Beutler, who are looking for therapist-patient matching keys to how to work most effectively, but I am not impressed by the depth of their findings (even though I keep hoping that there will be something there).

 

 

Michael Basseches, 14 June 2000

Thanks, George. So would the following qualify as a response to the challenge or is it a side-stepping of the challenge?

While common factors may be one set of significant contributors to therapeutic change, and aspects of therapist-patient match may be another set of contributors, differential effectiveness may be found in variations in therapists' intellectual and interpersonal abilities (to which effective therapist training can hopefully contribute) to understand and work through a less than optimal match and to transform it into a successful therapeutic relationship.

I believe that this set of of perspective/ability/training/experience factors represents a third very important set of contributors to therapeutic effectiveness (to which SEPI has, and should continue to attend). I think both Tullio and my posts were efforts to address this issue. Does it indeed address the Do-do challenge.?

 

 

David A Shapiro, 14 June 2000

Actually it was Rosensweig in the 1930's who first applied the Dodo metaphor to psychotherapy research. Subsequently, Bill Stiles, Robert Elliott and I took up the theme in our 1986 American Psychologist article, "Are all psychotherapies equivalent?".

 

 

George Stricker, 16 June 2000

To Mike Basseches:

I don't think that the set of factors you mention (and I agree with your sense of their importance) speaks to the Dodo bird issue, because those factors do not differentiate the orientations and the final verdict, all must have prizes, still holds. However, whether or not you read the Dodo as I do, you still are presenting a hypothesis, and it would take empirical data to address the Dodo and provide contrary evidence.

To David Shapiro:

I wasn't aware of Rosenzweig's use of the term, but the Luborsky review was in the early 70s and preceded your article. When it comes to the provenance of a term like Dodo bird, I don't think we can be sure of anyone other than Lewis Carroll.

 

Tullio Carere, 17 June 2000

George Stricker wrote: "The Do-do bird challenge is to find differential effectiveness and, by doing so, get beyond common factors as the basis of all therapeutic change."

This is surely a way of reading the Do-do issue. Another way, in my view no less legitimate, is not to get beyond common factors in search of differential effectiveness, but on the contrary to stay within the common factors, and look there for the basis of all therapeutic change. I dare say that the latter reading is even more legitimate, because if "All have won and all must have prizes", the outcome cannot depend on the method-specific factors in the first place, but it must relate primarily to those factors that are common across all orientations.

The standpoint, then, radically shifts. The focus is no more on a theory of the mind, as in most psychotherapeutic traditions, but on the therapeutic relation, and specifically on the question: what is therapeutic in a therapeutic relation? (and its twin question: what is pathogenic in a pathogenic relation?). Do we need empirical research to know that an abusive relation is pathogenic? I don't think so. By the same token, we should not need empirical research to know that theoretical abuse is what turns a would-be therapeutic relation into a pathogenic one.

But could a therapist who clings to his theory or manual not be abusive? I don't see how he could. This means that manual- or theory-driven treatments are fine for research aims, but they are no real therapy. On the contrary, they are surely abusive in the long run. It follows that the first and foremost common factor to any therapy is the freedom from theory, which does not mean to have no theories--it means not to be conditioned by them, that is to be able to suspend them, to remain in a (relatively) theory-free space. Which corresponds, besides, to the time-honored first duty of all therapists: primum non nocere.

Michael Basseches wrote: "Your second answer -- suspending theoretical and personal preconceptions -- may be one way of attempting to avoid harming clients within therapy relationships, but I have trouble endorsing that one because I think (as you do, I believe) that it is impossible to do so completely, and also, because there are many other skills required in this effort as well."

The suspension of all theoretical and personal preconceptions cannot be anywhere near perfection, but it must be "good enough" to allow at least for the beginning of a negotiation--how could a negotiation ever begin if one refuses to yield his/her truths? (And you are the first among us to alert to theoretical abuse). We may then be even more ambitious, if we don't content ourselves with negotiations but we want to know what one person really needs (beyond all theories, techniques, and constructions).

If the suspension of all theoretical and personal preconceptions - the phenomenological epoché - is the basic common factor of all therapies worth the name, it is also the base from which to start, and to which always return, to investigate on all other common factors. Failing this, we would only have theories and would be prisoners of them (which has in fact happened to the psychotherapy schools--couldn't SEPI be a remedy?).

Hilde Rapp wrote: "How about the phoenix verdict?"

That's another bird. As you know, the phoenix lives very long, and goes into fire only at the end of its long life. Psychotherapy is still very young. There will come a time for the phoenix, but it seems the Do-do is our bird now.

 

 

George Stricker, 17 June 2000

I think Tullio and I were saying something very similar, but from different perspectives. I spoke about the Dodo challenge (to find differential effects) and he about the Dodo effect (the importance of common factors). Two sides of the same coin, as I see it. I also agree on the problems of manualizing that which should be more responsive to idiographic occurrences. However, there are two points on which we disagree, I think. The first is the value of empirical data. There are many things which are obvious (e.g., the sun moves around the Earth), but do not stand the test of investigation. The second is Tullio's statement "It follows that the first and foremost common factor to any therapy is the freedom from theory, which does not mean to have no theories--it means not to be conditioned by them, that is to be able to suspend them, to remain in a (relatively) theory-free space." I think he is speaking about a wish rather than an empirically verified finding, especially as it is the case that many therapists are theory-driven, to the detriment of their work, but that means that being theory-free clearly is not a common factor. I think we also have to be aware of the distinction between the role of theory in understanding what is happening (critical, in my view) and its role in determining our interventions (secondary, again in my view, and I think in Tullio's as well).

 

Tullio Carere, 17 June 2000

George Stricker wrote: "I think Tullio and I were saying something very similar, but from different perspectives. I spoke about the Dodo challenge (to find differential effects) and he about the Dodo effect (the importance of common factors). Two sides of the same coin, as I see it."

I totally endorse this view. On the one side of the coin I put theoretical integration (the assimilative avenue), on the other side the common factors approach (the accommodative avenue).

George: "I also agree on the problems of manualizing that which should be more responsive to idiographic occurrences. However, there are two points on which we disagree, I think. The first is the value of empirical data. There are many things which are obvious (e.g., the sun moves around the Earth), but do not stand the test of investigation."

To me this is another coin, or better said the same coin at another level. On the one side there is theoretical-empirical science, based on hypothesis testing; on the other side there is descriptive-phenomenological science, aimed at the uncovering of evidence. If this dialectic is lost, science is lost too.

George: "The second is Tullio's statement "It follows that the first and foremost common factor to any therapy is the freedom from theory, which does not mean to have no theories--it means not to be conditioned by them, that is to be able to suspend them, to remain in a (relatively) theory-free space.": I think he is speaking about a wish rather than an empirically verified finding, especially as it is the case that many therapists are theory-driven, to the detriment of their work, but that means that being theory-free clearly is not a common factor."

This is right what I meant: when therapists are theory-driven, it is to the detriment of their work. Saying that "the first and foremost common factor to any therapy is the freedom from theory", I meant any genuine, non theoretically abusive therapy.

George: "I think we also have to be aware of the distinction between the role of theory in understanding what is happening (critical, in my view) and its role in determining our interventions (secondary, again in my view, and I think in Tullio's as well)."

My view here is slightly different. Instead of seeing the role of theory as critical in understanding and secondary in determining our interventions, I prefer to balance the theoretical-interpretive moment and the phenomenological-intuitive one in both.

 

 

 

 

George Stricker, 17 June 2000

It seems as though Tullio and I have reached agreement, despite the apparent differences in the original presentations. There is one point he made well that I would like to reiterate: "To me this is another coin, or better said the same coin at another level. On the one side there is theoretical-empirical science, based on hypothesis testing; on the other side there is descriptive-phenomenological science, aimed at the uncovering of evidence. If this dialectic is lost, science is lost too." I agree totally, although I, with Reichenbach, prefer to refer to this as hypothesis generation and hypothesis testing, and the dialectic nature of these processes, which Tullio refers to, is crucial, and there is no need to choose between them.

 

 

Zoltan Gross, 17 June 2000

May was an extraordinary month for me. In the beginning of May, I attended and presented at the SEPI Meetings in Washington, D.C. and at the end of the month I went to the Conference on the Evolution of Psychotherapy (CEP)in Anaheim, CA. At both meetings, the presenters talked about psychotherapy in different languages. They had different conceptions about what the nature of help was or should be. Underlying these differences were different assumptions about the task of psychotherapy. The presenters described what they thought psychotherapy "looked" like and it looked different to all of them.

This is not an unusual observation. Minuchin at the CEP meetings commented on the fact that the diversity of explanations about the nature of psychotherapy was both enormous and intelligent. He went on to say that all of the presenters believed that they were "effective" therapists, including himself. He also noted that it is remarkable that so many dedicated and talented men and women have examined the two person therapeutic relationship have come up with so many different explanations about its nature. Furthermore, he said that regardless of their explanatory differences, they were all helpful (the Do Do Bird). I agreed. I saw it with my own eyes. The interviewees invariably left their fifteen minute sessions expressing gratitude for the help they received.

The bedlam of voices caused me to think they were talking about different interpersonal enterprises. This observation puzzled me. If they were different kind of relationships, why, then, did all of the interviewees express the same appreciation for the different kinds of help they received? The clatter of explanations had such a dizzying effect on me that I turned the sound off. The quieting peace that followed allowed me to look at what these different therapists were doing with their client/patients, without being distracted by my confusion about their different explanatory systems. I was struck by how much alike they looked.

Of course, the therapists were clearly different in their personal presentations. Albert Ellis' aggressive assertiveness was different from Eugene Gendlin's gentle empathy or Leslie Greenberg's "Santa Claus" geniality. Yet they were all authoritative and had the presence and wisdom that comes with years of practice and teaching. They were all respectful and comfortable. They were clearly interested in being helpful. At the beginning of each demonstration, the presenters gently took care to put their clients at ease. All of this was done without asking anything in the way of validational feedback from the interviewee. At the same time all of the therapists were powerfully present with their interviewees. They made eye contact and continually sending nonverbal signals of approval and understanding to the client/patient. They were all quiet, warm, nonjudgemental and intuitively empathic, wanting to have a clear understanding of how the interviewees experienced their distress. They asked the interviewee to describe the problem that brought them to the interview. The therapist asked penetrating questions until he or she understood the problem the interviewee about which he/she wanted help. These questions demonstrated the intelligent interest of the therapist and conveyed to the client/patient that she/he was in competent hands. The therapist carefully proceeded to reframe their interviewee's problem in his/her own terms. The therapist's restatement of the problem caused the interviewee to think about his/her problem in a new way and provided him/her with a way of thinking about the problem in the therapist's language. The client/patients were given a new cognitive perspective on the nature of her/his distress.

Where else in life can a person get this kind of undemanding, knowledgeable, good willed attention? I disagree with Tullio's contention that therapists are engaged in an "ordinary everyday relationship." They were engaging in a relationship which I believe is a Twentieth Century interpersonal invention. It takes years of clinical practice to become comfortable and skilled in this kind of relationship. To me the therapeutic relationship is related to but not identical with Buber's description of the "I-Thou" relationship. The similarity of approach by the therapists I saw is partially responsible for the Do Do Bird effect. Other variables also operated to produce the differential effects to which George Stricker calls our attention.

Three kinds of information will help us escape from the banality of the Do Do Bird's prizes. We need a better understanding of the dynamics of dyadic interaction. None of our current explanations of dyadic interaction enables us to describe the moment to moment music of emotional experience that arises when two people are personally involved with one another. Related to this, we also need to know much more about the contribution that the therapist's person plays in psychotherapy. I look forward to results John Norcross' commission looking into this matter. While there is evidence that therapists differ in their effectiveness, there is no research studying the role of the therapist's person in the therapeutic process. That information would provide us with valuable information about the nature of therapeutic effectiveness. Finally, more clearly specifying the goals of therapy will help us to see the differences in the therapies as well as their similarities. There is a real difference between therapies that are devoted to character change and those that seek to provide relief from the distress of affective disorders.

 

 

Hilde Rapp, 19 June 2000

The 'phoenix verdict' is just an invitation to consider a paradigm shift – of the sort that would allow us to consider the Do-do challenge (to do, to attend to what we do reflectively, and not to become extinct) and the Dodo verdict (as explained by George) in the same frame. To suspend and conserve both perspectives in a meta-frame: what is common and how is this non trivial – ie distinctive to therapy rather than any broadly emancipatory activity, and what is distinctive. Core competencies and specialist competencies: core competncies which transcend orientations, and specialist competencies which are theory, technique, modality or context driven.

As you know Tullio: the bird which comes out of the fire is the same bird which went in – just with some of the dross burnt clean in the purifying flame – and that which was good distilled and fortified...

PS: Let me know if you want me to stop being poet and mystic and start being craftswoman and scientist – the philosopher cannot be dispensed with.

 

Tullio Carere, 21 June 2000

Zoltan Gross wrote: "I disagree with Tullio's contention that therapists are engaged in an "ordinary everyday relationship." They were engaging in a relationship which I believe is a Twentieth Century interpersonal invention."

I didn't say that. I said that the factors that are common across therapies are embedded in ordinary everyday relationships, and Mike rightly added that what is harmful is also embedded in ordinary everyday relationships. Hence the key questions: what is basically therapeutic in a therapeutic relation, and what is basically pathogenic in a pathogenic relation? In the search for an answer, I inverted the order of the two questions: if the first pathogenic factor is theoretical abuse (as Mike showed in his groundbreaking works), the first and foremost therapeutic factor must be theoretical

freedom, that is freedom from any theoretical allegiance.

But is theoretical freedom a feature of ordinary everyday relationships? Though it is not very ordinary, it is present wherever a genuine dialogue takes place. Genuine dialogue is the common ground of all genuine therapy, and it is not a Twentieth Century interpersonal invention. As in the Fifth Century B.C. the only true philosopher was the one who knew that he did not know, so in the Twenty-first Century the true therapist is the one who does not cling to his/her theories. In all ages the ignorant are the ones who cannot suspend their preconceptions and beliefs, among which the most dangerous are those whose unquestionable truth is said to be supported by religion or science. There seems to be not much really new under the sun.

Hilde Rapp wrote: "As you know Tullio: the bird which comes out of the fire is the same bird which went in – just with some of the dross burnt clean in the purifying flame- and that which was good distilled and fortified...PS: Let me know if you want me to stop being poet and mystic and start being craftswoman and scientist- the philosopher cannot be dispensed with."

If the true therapist is a true philosopher in the first place (i.e., one who knows how to bracket out all knowledge), his/her place is nowhere--he/she is 'atopos', as they used to say. Or one could say that it is anywhere between knowledge (science, technique) and unknown (mystic, poetry). Provided that he/she is at pains not to get stuck at either side of this polarity, all movements on this line are fine, in my view.

       

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