Psychotherapy Integration

Editor's Note In preparation for the 2nd Sepi- Italy Conference, held in Florence from 24 to 26 March 2006, Tullio Carere asked the speakers of the Conference and the members of the Sepi listserv to participate in an on-line debate. In his e-mail dated 22 January 2006, Carere proposed a series of questions which have been the starting point for a rich and passionate discussion among 16 participants (listed in the order in which they intervened) : Tullio Carere, Paul Wachtel, John Norcross, George Stricker, Allan Zuckoff, Hilde Rapp, Tyler Carpenter

Tullio Carere, 2 February 2006

Thank you dear Hilde for your rich response, which reflects your vision of psychotherapy as art and science - which is also my vision. Medicine too is art and science, but psychotherapy is such in a very special way, given its kinship with natural sciences on one side and human sciences on the other. Our field has not yet been able to find a viable integration between these two sides. You acknowledge that there are "different traditions which are linked to different practices", one "diagnostically driven", and the other of "more humanistic type". But the difference you underscore is between two opposite thrusts, one adaptive/normalizing, and the other actualizing/self-realizing. If this were the point, your observation that "most good, and most integrative psychotherapist would see a positive value in both these  endeavors" would solve the problem, and the integration between the two traditions would already have been happily realized. In my view this unfortunately is not the case.

As a matter of fact, there is a big rift between the two sub-fields. Here is how I describe the relevant difference: Those "diagnostically driven", as you fittingly name them, apply the simple principle of diagnosing a disorder, a problem, a need, or a phase, and prescribing the (empirically supported) procedures to fix the disorder or the problem, or to meet the need or the phase. This frame of mind is commonly called "medical model", because it corresponds to the medical treatment as it is conceptualized in our time. On the other side, the adherents to the adversarial perspective, often called "contextual model", maintain "that psychotherapy is incompatible with the medical model and that conceptualizing psychotherapy in this way distorts the nature of this effort" (Wampold, 2001). They propose as an alternative a holistic/contextual approach, in which common factors are emphasized to the detriment of procedures (which are reduced to mere placebo). Both sides support their views with enormous amounts of empirical research; both sides maintain that the approach of their side is the one that best meets the needs of the clients; and both sides dismiss the other as simply wrong if not harmful. As Westen put it, "the intensity of the acrimony, the distaste, has never been so high."
 
If we want to come to terms with this split, we might start with a few things. To begin with, we should not deny its existence. A way both sides have to dismiss the other is to simply deny their existence as a partner of a dialogue or a negotiation. If the other does not exist, why should we waste our time with dichotomies or polarities? It is pointless. Secondly, we should get rid of the myth of scientific neutrality. If X and the opposite of X are both empirically supported, we cannot ask empirical research to solve the problem (I am not saying that empirical research is useless, but only that it cannot solve this problem). Thirdly, it is clear that no reconciliation is possible between the medical and the contextual model. But do we really need them? They are both abstractions far from everyday practice. In the "common sense" model every therapist makes use of some procedures which they deem useful -  therefore they are not contextualist. But nobody applies them in a protocol mode: they use heuristic, rule-of-thumb procedures, and adapts them to the present circumstances -  and every patient responds to their therapist's procedures according to the way they understand them and the way they need them. Everything happens out of a great deal of improvisation and "sloppyness". Therapy works when there is a good enough working alliance, which is not the result of protocols, but of ongoing negotiations. In the common sense perspective there is room for both procedures and context: at this level integration is possible, whereas what we get from the protocol-driven and the contextual perspective is the split of the field.

In the common sense perspective it is not so important to separate the procedures from the context. What is crucial instead is to correlate process and outcome, i.e. to understand what transpires in the clinical (not the experimental) setting that explains the progress, or the lack of progress. It seems to me that empirical research is much more useful when it tries to illuminate this matter, than when it claims to prove or disprove the efficacy of procedures independently of the context. This is my response to my own questions.

Hilde Rapp, 6 February 2006

Tullio wrote:

<< You acknowledge that there are "different traditions which are linked to different practices", one "diagnostically driven", and the other of "more humanistic type". But the difference you underscore is between two opposite thrusts, one adaptive/normalizing, and the other actualizing/self-realizing. If this were the point, your observation that "most good, and most integrative psychotherapist would see a positive value in both these  endeavors" would solve the problem, and the integration between the two traditions would already have been happily realized. In my view this unfortunately is not the case.
As a matter of fact, there is a big rift between the two sub-fields. Here is how I describe the relevant difference: Those "diagnostically driven", as you fittingly name them, apply the simple principle of diagnosing a disorder, a problem, a need, or a phase, and prescribing the (empirically supported) procedures to fix the disorder or the problem, or to meet the need or the phase. This frame of mind is commonly called "medical model", because it corresponds to the medical treatment as it is conceptualized in our time. On the other side, the adherents to the adversarial perspective, often called "contextual model", maintain "that psychotherapy is incompatible with the medical model and that conceptualizing psychotherapy in this way distorts the nature of this effort" (Wampold, 2001). They propose as an alternative a holistic/contextual approach, in which common factors are emphasized to the detriment of procedures (which are reduced to mere placebo). Both sides support their views with enormous amounts of empirical research; both sides maintain that the approach of their side is the one that best meets the needs of the clients; and both sides dismiss the other as simply wrong if not harmful. As Westen put it, "the intensity of the acrimony, the distaste, has never been so high." >>


I entirely agree with you, Tullio, that the field at this present moment  is divided and that debates are acrimonious.  However, I would want to argue that it is precisely because of this situation that integrative psychotherapy- where the emphasis is on the syllable –ative- ie an ongoing process- is necessary , and  that this was, indeed, the stimulus for the origination of the ‘movement’ for exploring the integration of psychotherapies.  We have had four recognized waves, the last being accommodative- assimilative integration.
  I am, however not describing the status quo, but rather I am actively and passionately  pleading for a fifth wave- as I believe are you- which advocates for meta- integration.  Meta- integration  can accommodate the historically existing differences because  increasingly integrative therapists set store by and are skilled in ‘negative capability’- ie the capacity to tolerate paradox, uncertainty, contingencies and ambiguity as inevitable properties of complex living systems.
 With this comes the recognition that any integrative ‘solutions’ will be local and specific and are likely to  relate to single lines of conflict. There are echoes here of Bion’s dream that there could be a grid that would allow us to specify a problem quite precisely- that we might be able to formulate a coherent question  by means of which to interrogate reality. But there is also the recognition that in fact we really proceed in a much more random fashion,  making use of  unexpected windows of  opportunity, leaps of the imagination, the availability of new descriptive and analytic tools as information technology improves, victims of the vagaries of intellectual fashion and the vicissitudes of everyday life as it presents populations with new anxieties, new challenges  and both news defenses  ( beliefs in panaceas, distractions etc) and new solutions, real or imagined. 
 The new skill is not so much the capacity to deliver sweeping answers which unify a universe of discourse- this would be my ‘quarrel’ with Ken Wilber’s ‘integral psychology’ as an attempt at a new ‘theory of everything’. The new skill would be  to have a methodology for transforming conflicts between assertions and positions by focusing on common needs and goals- perhaps also common factors- but more strongly on common functions:  What is the function of the client’s defenses or resistances?  How do they aim to meet the client’s needs- and which ones?- and what are their priorities in terms of the client’s assumptive world and value system? Is it bread or honor ? As it were. Echoes of Maslow would figure here and the contemporary expansion of his model into  a more differentiated hierarchy of needs in Spiral Dynamics. It is an enterprise that is both modest and bold.

Tullio wrote:
<<If we want to come to terms with this split, we might start with a few things. To begin with, we should not deny its existence>>.

Agreed. We need to bear the pain of its existence and accept  splitting and polarization as a part of the human condition and hence also the professional landscape, and we need to endeavor to understand  the psychological pressures which maintain these splits and conflicts.
 
Tullio wrote:
<< A way both sides have to dismiss the other is to simply deny their existence as a partner of a dialogue or a negotiation. If the other does not exist, why should we waste our time with dichotomies or polarities? It is pointless. Secondly, we should get rid of the myth of scientific neutrality. If X and the opposite of X are both empirically supported, we cannot ask empirical research to solve the problem (I am not saying that empirical research is useless, but only that it cannot solve this problem). Thirdly, it is clear that no reconciliation is possible between the medical and the contextual model. But do we really need them? They are both abstractions far from everyday practice>>.

 I am  reading this as description of the arguments advanced in the split field rather than as statements of your position- I am right in this?  As you can see from the previous response, I entirely agree  that the problems arises and is maintained by the fact that both positions are ‘abstractions from practice’.
 
Tullio wrote:
<<In the "common sense" model every therapist makes use of some procedures which they deem useful -  therefore they are not contextualist. But nobody applies them in a protocol mode: they use heuristic, rule-of-thumb procedures, and adapts them to the present circumstances -  and every patient responds to their therapist's procedures according to the way they understand them and the way they need them. Everything happens out of a great deal of improvisation and "sloppyness". Therapy works when there is a good enough working alliance, which is not the result of protocols, but of ongoing negotiations. In the common sense perspective there is room for both procedures and context: at this level integration is possible>>

 Hhmm… Yes I agree that at the pragmatic level, as confirmed by Lisa Najavits’ research,  senior and/or successful practitioners tend to be responsive to clients needs and hence use whatever heuristic approach  moves the client on with respect to insight and desired change. Experienced  therapists from widely different orientations are therefore more similar to each other with respect to their practice and their ‘theory in use’, what ever their ‘espoused theory’, than they are, by and large,  to  their more junior colleagues  from  the same theoretical orientation. It seems much more important to ask in the  first instance : what do you do? What does your praxis look like? What are you aiming to achieve, what are your goals? and  only then to ask for theory informed explanations of these praxis choices…

Tullio wrote:
<< whereas what we get from the protocol-driven and the contextual perspective is the split of the field>>
 
 I raise this in my chapter about research- the protocol driven perspective tends to  have its home in the research community, in that it is – for many- a favored  vehicle for formulating and testing researchable questions in a reliable and consistent way.  We need ask population focused questions: Does this approach work at all and if so how does it compare to its competitors? Does this intervention really work? For whom does it work? Does the change last? Obviously, unless there is as much standardization as possible there is no possibility to compare what therapist A does  with client A to what therapist B does with client B.  I don’t believe there is a serious expectation that therapy in natural environments should be carried out in such formalised ways.
Once there is evidence that a particular protocol does seem to deliver the desired clinical change reliably, it would seem foolish, in a cash strapped service, not to offer such treatments. The issue then becomes  what to do with clients or types of clients who do not seem to respond to generally effective  approaches designed to  target  the kinds of problems  these clients bring.  Most researchers and clinicians  are modest enough to recognize that such clients exist and that other forms alternative  help  may be needed. Even though advocates for a particular approach may not see it as part of their brief to find out  what needs to be done,  the extraordinary changes in which cognitive behaviour therapy is now conceptualized and delivered, including both relationship and mindfulness focused approaches, testifies to the openness of researchers and practitioners to exploring new ways of working in order to reach clients” that other beers don’t reach”.  
 Once  there is evidence that something does work in principle, we want to ask  process questions  concerning  how  ( perhaps even why?) it might do so. Within ‘hard science’ approaches this is done through experimental methods which focus on observable and measurable  variables.  
 
 So called  ‘contextual’ approaches do not ( or should I say should not?) make any claims  that the ‘soft’ science variables which underlie  their practice are ( with some exceptions) researchable by  certain ‘hard science’ means and they should not be expected to produce equivalent outcomes.  This is not to say that they should be exempt from the public health related question as to whether their approach   is capable of producing reliable   clinical change, ie works in principle and works for  particular  populations, and whether it works as well as its competitors, or whether it has a competitive advantage in relation to specific populations, and should therefore be publicly funded.
Historically, contextual approaches have struggling with  descriptive case histories and analytical formulations which address how or why certain kinds of therapist behaviours might successfully address certain kind of client behaviours, such as defenses, thought /feeling/behaviour patterns     (schemas) and how unconscious pressures and relationships might play a role in both. They have largely done so anecdotally, but in a way which is recognized as a sizable body of expert clinical opinion capable of guiding practice. There are good reasons for these differences in epistemology and methodology which I will come back to below.

Tullio wrote:

<<In the common sense perspective it is not so important to separate the procedures from the context. What is crucial instead is to correlate process and outcome, i.e. to understand what transpires in the clinical (not the experimental) setting that explains the progress, or the lack of progress. It seems to me that empirical research is much more useful when it tries to illuminate this matter, than when it claims to prove or disprove the efficacy of procedures independently of the context. This is my response to my own questions>>.

I suppose the ‘common sense’ perspective is actually still  an ‘uncommon sense’ perspective.  I agree, see above, that it is a ‘both-and’ scenario, where the real challenge for  my proposed meta-integrative approach is one of humility and cooperation in the face of the complexity of the human condition and the marvelous  achievements of the moral imagination we are capable of on a good day and the awesome depths of depravity we seem to be able to sink to on a fearsome day.   We need people who will examine the outer landscape of how human beings negotiate their conflicting needs through social contracts of one sort or another, and for this  behaviour focused ‘ normalizing’ approaches are extremely useful.
We equally need people who plumb the inner landscape of  how we attribute  meaning to our passions, dreams and fears. The kinds of measurement  that are fit for calibrating a psychic plumb line  that reaches into the depths of meaning making are not the same as  those fit for  regulating socially adaptive behaviour by means of  guidelines that map our social skills.
 However, social skills without the attribution of meaning are empty, mechanical   and soulless, and  efforts after meaning without the social skills to share them with others,  leave people isolated, without role or relationships  on the margins of the social world.
 
Only by each bringing to the table  the best we can offer by way of tools for enquiry, ways of reaching out to lonely, frightened, lost, confused and deeply troubled fellow human beings, and ways of satisfying our social institutions that taxpayers money is invested ethically and effectively, can we move forward : in other words only by integrating the fragments of what we know and know how to do well, can we serve humanity as psychotherapists and mental health professionals…  
This means loosing our fear both of healthy competition and of  accountable co-operation…

Ken Benau, 7 February 2006

Hilde wrote:

<<However, social skills without the attribution of meaning are empty, mechanical   and soulless, and  efforts after meaning without the social skills to share them with others,  leave people isolated, without role or relationships  on the margins of the social world>>. 

I simply want to say, bravo! Having worked with many developmentally challenged children and adults who have deficits in social skills, but usually lack an appreciation for the reason, i.e. one that gives them meaning/purpose, to apply said taught skills in the first place.  The "depth" folks and the "behavioral skills" folks have much to teach each other, if we can only listen. 

As a serendipitous aside:  an Asperger adult client of mine recently ended a session telling me why he believes there is a link (in Asperger's/high functioning Autism) between deficits in mirror neuron functioning and executive functions... I don't know his theory yet, but he's obviously been doing his reading and I am very curious... So I should add, if we can listen to our clients, too.

Hilde Rapp, 7 February 2006

Dear Ken,

Thank you for your feedback.  I also have some experience of working with people suffering from neurological or developmental deficits and learning difficulties. I am struck by the level of insight  some people do have into their difficulties and how imaginatively they talk about them by  making use of metaphors where they lack access to – or the capacity to understand- relevant scientific research.   We can often help by amplifying their ‘naïve theory’ with research, where we ourselves know any. This  seems to help clients make sense of their difficulty better. It helps them to normalize and accept it and it encourages them to co-develop and practice relevant  coping mechanisms with the therapist.

From a practical perspective even a ‘superstitional’ pseudo theory can function like this because any explanation that makes subjective sense  to the client will lessen anxiety and hence lower the threshold for responding to therapeutic help… 

 I tend to translate into appropriate language that a client can understand something to the effect of  “ Given what is going on in your brain/ nervous system/endocrine system…etc  it is to be expected that you should have this difficulty. It is a normal consequence of your impairment.  Let us look  in detail at how this makes your life difficult and let us  work out together what you might do  to make it easier to  function despite your impairment… 

 This can be learning to breathe, speak in a particular rhythm to overcome dysarthria and speech problems which seriously get in the way of communication. Or it can mean helping a client  learn to  understand the anxiety reducing effect of gaze avoidance in intimate situations ( Michael Argyle studied this in Oxford in the seventies),  and to help a client to use gaze avoidance with awareness by  learning to say to an interlocutor: I am sorry I  have difficulty  looking you in the eye while  I talk to you  because  it makes me  loose my thread…. And so forth… 

 All this develops  out of  the therapist’s deep respect for the client’s wish and need to make meaning of their difficulties through listening ‘deeply’ as Rogers once put it. Our task is  to accept,  amplify, clarify, and  transform what the client knows about themselves and then to add, as necessary, new skills and understanding which enrich the client’s repertoire. 

 It helps enormously if we understand enough about normal and abnormal human development and physiology and the effect of adverse  events and environments on both. To know something about 1) normal responses to abnormal circumstances or  2) normal sequelae of abnormal development, or conversely, 3)  abnormal ( neurotic or psychotic) responses to normal environments, and of course, 4) developmentally normal responses to normal situations  is very helpful. It empowers the therapist to convey to clients that their experience is understandable and expected in the light of research. This  provides a  sound basis for helping people to drop developmentally superseded defenses and to develop more age appropriate ones,  to overcome abnormal defenses to’ objectively’ non threatening stimuli , and or  to  explore ways of using the plasticity of the brain to bypass  a current loss or distortion of function.  

Here it is  the ‘contextualists’,  especially within psychoanalysis and constructivism have rekindled the passionate interest Freud had in understanding the links between the physiological ( phi) and the psychic ( psy) as he explored this and theorized this in his project for a scientific psychology by  participating in neuroscientific research. In addition, especially analysts, have been revisiting and working collaboratively with  academic experimental cognitive and social developmental psychology, while cognitive behaviour therapists  have  from the outset been grounded in  academic  research that focuses on the connections between beliefs, attitudes, emotions and behaviour. The difference seems to be largely one of language, what is impulsivity in one quarter becomes lack of mentalisation in an other and what might be time out and thought stopping in one tradition might become reflective functioning in another… 

 It is all out there for the taking  if we  are not too frightened to leave our silos… 

Tullio Carere, 9 February 2006

Tyler Carpenter wrote:
<< To me to be therapeutic is simply to say I got the mix right this time with this person.
........
 To split such things into meaning-medicine-technique, except for the purposes of teaching or
 discussion, is to miss a complete understanding of the entire phenomenon at hand.>>

I agree, Tyler. It seems to me that you apply a common sense model (like most of us?). The problem with this model is that the mix that looks right to you might look wrong or arbitrary to others. If we don't rely on empirically supported procedures (possibly because our faith in the external validity of ESP is too weak), how do we know that our mix is right? If the validity of our work is not guaranteed by the strict adherence to some e.s. protocols (a guarantee widely accepted these days), do we have any alternative to producing objective material, like post-session questionnaires or session recordings, to monitor and document our work?  

Tyler Carpenter, 9 February 2006

I suspect that we all share more than a little "horse sense" in our work, Tullio, though I greatly admire the clarity and particularity that you and Hilde bring to your explanations of what you do. 

 For me in the prison, where I work and play, there was a period not a little like an initiation where one is tested and left on one's own a lot. With so much at stake you are watched carefully for your ability to manage what comes your way and to others. A gradual accretion of successful public experiences gives you credibility and things get easier and you're trusted and called on for the tough stuff. In other words, one can believe whatever one wants about what one does (and others can think what they like about you), but how things turn out is what makes the difference. Perhaps that is the prison version of EST. There are a lot of terms for pseudo courage and ability in this sub-culture. The issue is not what you call it or where you said it came from, but what you can do. I have to say that I thought I was pretty good before I went to prison. Now I know, and so do others, what I can and can't do. The best complement I ever got was in a Super Max when the Captain, who had heard others refer to me as "Doc", asked me if I was one. I told him I was one and he reacted with vehement disbelief for a few weeks until I showed him my license. I asked him why he didn't believe I was one and he said simply "You don't talk like one." In these places it boils down to the basics.  I once watched while a consultant (chosen by some experts new to prison work) who spoke all the right behavioral stuff came to help out a stalemate in maximum segregation. I have an M.A. in general-experimental psychology and understand what operational analysis supposed to accomplish. The consultant used models that came from the literature that completely failed to take into account factors that drove the behavior and undergirded the system. The result went nowhere. Whatever you call it and wherever it comes from, it won't work if you don't know how to apply it. This is the great lesson of places like prisons. People come from outside to apply what works one place without understanding the context. John Gall's "Systemantics" is a marvelous example of the importance of thinking about context and what goes in it and how that might change what happens in strange and chaotic ways.  Part of the problem is to go beyond articulating the divisions and take the leap into talking about how meaning is simultaneously diagnostic and biological and dynamic and contextualized in systems. The only SEPI presenter I ever talked with who would directly talk about the more molecular levels of system  and their interaction with things like meds was Bernie Beitman. When he talked about how people needed to want to change for meds to work I was floored. Now after working with dangerous and psychotic character disorders for years at a stretch, I see how the seams to the work can be brought by the therapist's models and that when transmuting experience in the dyad with a treatment team and multiple models and multiple staffs reduces symptoms and brings satisfaction, that 's the kind of result that goes beyond models and arguments. Our team had a marvelous time talking about a stalker whose vulnerabilities were ego syntonic.

How do you talk and think about target for meds when there is critical disagreement on meaning between patient and team and context is variable, but necessary to get therapeutic leverage?!

 I'd love to have a fraction of the protected time I had as a junior PI at Harvard now as a clinician in the trenches, but am too busy putting out the fires that are brought my way.  

Tullio Carere, 20 February 2006

Hilde wrote (on February 6):
 
<<The new skill is not so much the capacity to deliver sweeping answers which unify a universe of discourse- this would be my ‘quarrel’ with Ken Wilber’s ‘integral psychology’ as an attempt at a new ‘theory of everything’. The new skill would be to have a methodology for transforming conflicts between assertions and positions by focusing on common needs and goals- perhaps also common factors- but more strongly on common functions: What is the function of the client’s defenses or resistances? How do they aim to meet the client’s needs- and which ones? - and what are their priorities in terms of the client’s assumptive world and value system? Is it bread or honor? as it were. Echoes of Maslow would figure here and the contemporary expansion of his model into a more differentiated hierarchy of needs in Spiral Dynamics. It is an enterprise that is both modest and bold.>>


I agree, Hilde. Every theory of everything is bound to clash with other theories of everything, as religions have always done and still do. An "integral psychology" has more to do with integralism than with integration, in my view. And I strongly endorse your idea that in order to transform conflicts between theories we should focus on common needs, goals and functions. My own formulation of the same idea is that in order to transform theoretical conflicts we are bound to move to a non theoretical ground - and this ground is the common ground where we find all common needs, goals and functions. This implies that we don't need a theory of the common ground - if I put forth a theory of it, somebody else will put forth another theory that will be no less empirically supported than mine, and there we are again. This is where the common sense comes in.

You write:
<<I suppose the ‘common sense’ perspective is actually still an ‘uncommon sense’ perspective>>.  

Yes, common sense is still quite uncommon. But we can try to make it a little more common, if we understand how badly we need it. Many believe today that psychotherapy integration can only happen on the ground of empirical (especially experimental) research. I believe that this belief is the main reason of the big rift in our field. Besides, it encourages all schools to empirically support their theories, and in the end the Dodo bird is the one who wins. The faith in empirical research, as applied to psychotherapy, does not seem to have any integrative effect on our field. To the contrary. If we hope to be able to communicate among us, shouldn't we return to the commonalities (to the things themselves, as Husserl put it), i.e. to the basics of experience? And how do we get to these commonalities, if not on the ground of common sense, that is the sense that is common to everybody who is willing to use it? We all can use our abilities of intuition and argumentation (nous kai dianoia, as the Greek knew well), but the correct use of these requires a disciplined mind, a mind that disciplines itself by means of epoché, or suspension of memory and desire, or similar ways. Of course this is quite unzeitgemaessig for our undisciplined Zeitgeist. Yet, controlled clinical trials and statistic processing of data are poor substitutes for disciplined minds. Maybe a growing number of therapists and researchers will realize that. If this happens, common sense will be a little less uncommon in our field. 

Hilde Rapp, 20 February 2006

Dear Tullio,

Thank you and a general reply in haste with apologies: John Norcross was quoted in the UK guardian  this week ( have you seen it John?) with a sort of reply by Andrew Samuels, a prominent Jungian- in a piece which argued, as you have done, Tullio, that there is practically a war on between lets say the psychoanalytic and person centered imagination and the empirically  researched  approaches to treatment.  Although probably not meant to be inflammatory, Andrew argued that some people need a more sophisticated, ‘nuanced’, as he called it, approach. 

 I think this is unfortunate because its draws false distinctions, to which Paul Salkovkis would justifiable rise with passion. Both sides  are sophisticated and nuanced, both sides set store by ‘epoche’ ( I do too, and strongly- although I also humbly think we are relatively bad at suspending preconceptions as a biological species – at least we should aim  for it!) both sides are well schooled in philosophy of mind and science- and both sides are  passionately committed to bettering the lot of suffering people. 

 That is the common ground position.  

 So why the near war?  

 In the seventies there was a fierce Methodenstreit- a battle of methods between the ‘human sciences ( Geisteswissenschaften) grounded in hermeneutics , lead by the Frankfurt School ( TW Adorno) on one side and Karl Popper as the representative of the positivist camp  on the other          ( contributions were collected by Erst Topitsch in German)…We should really get round to recognizing that we do precisely neither have a theory  of everything nor a corresponding epistemology for everything that is coherent and systematic. We can  understand facets in detail and we can  understand the relationship between these facets in general, ie we can have a metatheory  which helps us to locate and relate facets of understanding to one another.  

 It is surely positive that we can and do have vigorous, passionate, and on occasion, even rigorous debates about which shoe fits which foot and which glass slipper does not.

My only regret is that we do,  all too often get carried away by our passions to the extent that we forget to be respectful. Then  we argue ad hominem  instead of ad argumentum or factum  - and we forget that not everyone speaks Latin or statistics or  Latino-Greek nosology and psychiatric classification or post modern contextualist jargon – or dare I say it- English!.  So we should be polite and translate. 

 We need to humanize our dialogue without loosing our commitment to the original Platonic purpose of dialogue- namely to arrive at approximations to the truth(s). 

 We also need to humanise the dialogue in the sense of remembering that much of the quarrels are not about truth(s)  or facts, but about values.

Values, by definition are not strictly speaking , based on rational decision making or indeed empirical validation- as both researchers and modelers know only too well. They are about life choices, about preferences, about ethics and aesthetics.    

 These preferences will never be unified- and in that sense Andrew Samuels in right-  our tastes will always be nuanced and there will always be people who prefer one style of therapeutic interaction to another. 

 There is – in my view- however far too little serious dialogue  about the basis on which decisions are made about  funding psychological services  and what  epistemologies and models , methodologies and  methods  can be agreed to be  mutually acceptable to demonstrate that services deliver the outcomes they are  set up to bring about ( Health Technology Assessment,  in the UK) . Here we get into health promotion, social inclusion, ethics, health economics and  models of needs assessment and so forth : what the public may demand/want may not actually meet their assessed need ( I have early lung cancer \and I want a fag,  may meet a psychological need but contravene a medical one)  and what services want to supply may meet demand, but not need ( I want to sell cigarettes because I have a pile of them, but people actually need food).  This no longer has much to do with theories of psychotherapy- although it does have something to do with models of (wo)man, philosophy of science, and the mind and morals…and it also has to do with research by medical anthropologists , sociologists and social psychologists…

Paul Wachtel, 20 February 2006

Hi Tullio and Hilde,
    Looking forward to seeing you both soon.  Tullio, I think we will find, when we get into the in-person discussions, that, as we might expect, there are both agreements and disagreements (which is, of course, what makes the whole thing interesting).  I think one of my biggest disagreements is that you have, in my view, much too much faith in the "disciplined" mind.  As I think I stated in a previous exchange on the sepi listserve on Bion, "without memory or desires" seems to me like with self-deception.  But apart from the specifically Bionian version, I simply don't think we can be nearly as disciplined as you give us credit for.  I think the entire scientific enterprise dovetails exactly with Freud's main message (even if Freud himself -- perhaps illustrating the very point -- didn't always heed this) -- that our capacity for self-deception, for seeing what it is convenient to see, is utterly enormous.  The controls of systematic empirical research are not a perfect solution, not a panacea, and it is certainly true that if we take the findings of any particular study (or even line of study) as gospel, this is just another form of self-deception.  But I still think that the controls of systematic empirical research are very substantially better than the "discipline” the lone clinician can muster.  So, although I myself have not been primarily an empirical researcher (and hence, as you might imagine, I don't believe that is the only path to knowledge) I do believe that disciplined and serious critical and integrative thought (which, I guess, is what my own contributions largely consist of -- when I'm doing well) cannot be very useful unless it pays very serious and careful attention to systematic empirical research.  Reversing your sentence, I would say that "disciplined minds" can be poor substitutes for controlled clinical trials and statistical processing of data -- although I don't think controlled clinical trials are always the best way to investigate particular questions and indeed, are often used (and set up) in highly tendentious and misleading ways.  Critical thought is always needed.  I'm certainly not advocating giving up our minds for our statistical programs.  But I think you are too cavalier and dismissive toward empirical data.  The dodo verdict either reflects a real phenomenon (in which case we need to take it seriously in our thinking) or poorly conceived and biased studies (in which case we need to examine the sources of potential bias and do better studies), but it is not a reflection of the inadequacy of empirical research per se. 

   I'm all for common sense.  But unaided it often doesn't get us very far.  Common sense tells us the world is flat, the sun revolves around the earth, etc.  Quantum theory, relativity theory go against "common sense."  Sometimes, it is the non-intuitive, the idea or finding that challenges our intuitive sense of things that is what we need to be open to. 

    If you're saying that we need to be wary of the arrogance of the "empirical" or "scientific" finding (also to be put in quotes) I am 100 percent with you.  But if we substitute for that the arrogance of our clinical observations, or intuition, or common sense, then we have gained very little.

    But enough. It's hard to do this at a distance (I'm not of the generation of instant messaging) and it always sounds more adversarial when put this way.  When we see each other in a few weeks, and can talk about it over a cappuccino, then we will make progress in the conversation.

Paul Wachtel, 20 February 2006

Just read Hilde's contribution after sending the reply to Tullio.  I think in many ways Hilde is making similar points to the ones I made.  So when the three of us (and John, and whomever else) have that cappuccino, my guess is that (a) we will have a very interesting conversation [actually, that one's a no-brainer -- because the people aren't); [b) that we may well find that our particular points of agreement or disagreement are different than they seem on the email exchange.  I say this because I assume (I think correctly, that however the conversation has been tilting in response to previous tilts [ad infinitum?] , we all in fact agree that there is no single path to truth and that multiple perspectives are essential.  So what will get really interesting is when we try to go past that bland generality (which also, of course, happens to be at the same time a profound truth) and see just where and why we do depart.   

David Allen, 21 February 2006

Tullio, Hilde, Paul:

Don't we all agree that we need both empirical research to reduce the biases of clinical observations AND clinical observations to reduce the inherent limitations of our ability to measure psychological constructs in empirical research?  Not only scientists but patients responding to psychological measurement can deceive themselves as well as others. The two methods of discovery compliment one another to my mind; another example of "both-and" thinking rather than "either-or" thinking.  In the same dialectical vein, of course every "theory of everything" generates a competing theory of everything.  The two of them are then reconciled, generating yet another thesis-antithesis-synthesis.  This is how knowledge grows as we get closer and closer to truth.  I think this is an argument in favour of the genesis of metatheories, not against it. 

Andre Marquis, 22 February 2006

Dear Paul, Tullio, Hilde, David, and everyone else:
 

To begin, I’d like to briefly introduce myself to the SEPI members and express my heartfelt thanks for a community that seems so genuinely devoted to non-parochial dialogue, in contrast to acrimonious debate. I join this discussion as assistant professor of counseling and human development at the University of Rochester, a mental health counselor fortunate to have been mentored under Michael Mahoney, a founding member of Integral Institute, and one of my primary interests is exploring various avenues of psychotherapy integration.
 
I have been reading the discussions on the SEPI listserv for the past four months, wondering when I might chime in; when Hilde mentioned Wilber’s Integral theory, I recognized my cue, which is also pertinent to the current dialogue on the role of empiricism and evidence-based practice. It does seem clear that the vast majority of SEPIites are deeply sympathetic to the current emphasis on accountability and recognize the need to ground our practice in evidence. It is necessary then, even if elementary, to delineate what forms of inquiry and evidence constitutes legitimate forms of data. As Gerald Davidson recently wrote http://www.apa.org/divisions/div12/homepage.html <http://www.apa.org/divisions/div12/homepage.html> , let’s bear in mind that “empiricism” derives from “based upon experience.” To limit our evidence to strictly controlled randomized clinical trials seems limiting indeed. I am certainly not opposed across-the-boards to the EST research protocols, but the stringent exclusion criteria, lack of clarity regarding reporting therapist characteristics, problems with strict adherence to manual-driven therapy, and less-than-optimal follow-up reporting (to name a few criticisms; EST critiques abound: Andrews, 2000; Carroll & Nuro, 2002; Messer, 2001; Miller, 1998; Persons, 1991; Seligman, 1995; Slife, 2004; Slife & Gannt, 1999; Weisz et al., 2000; Westen et al. 2004; Westen & Morrison, 2001) suggest that a plurality of complementary methodologies would more comprehensively inform our clinical work.
 
And here is one of the many controversies where I view the AQAL model (All-Quadrant, All-Levels, all-lines, all-types, all-states) of integral theory being particularly informative. Wilber’s quadratic model (I’ll confine myself here to quadratic issues) represents the interior and exterior of any occasion, individual, event, etc. That occasion, individual, event etc. can also be viewed as an isolated occasion or contextualized within larger systems. So, the inside and outside of both an individual/occasion and the larger systems/collectives in which that individual/occasion emerges yields 4 distinct perspectives from which to view and conceptualize any phenomenon. Reminiscent of the parable of the blind men arguing about  what the elephant actually was, it seems to me that systematically integrating methodologies from at least those 4 perspectives would mutually-inform each perspective and generally enrich the communicative exchange between researchers and clinicians. A simplified example of methodologies from each of the 4 quadrants appears below: (I just realized that a figure loses its formatting via email so it's more of a list; imagine the intersection of two axes: interior/exterior and individual/system)
 
    The Four Quadrants and Methodologies Appropriate to Psychotherapy
 
    Individual from Interior:  (Subjectivity): Phenomenological analysis of            
    clients’ experiences of therapy (Rogers, Bugental, May)   
 
    Individual from Exterior:  (Objectivity):  Empirical investigations –   
    from EST/RCT methodologies to other “objective” approaches such as
    neuroscience (Damasio, Siegel, LeDoux)   
 
    System from Interior: (Interobjectivity):  Systemic analyses (including    
    videotaped sessions) ala Greenberg’s (1999) intensive observation,
    measurement, and analyses of concrete-change performances; as well how
    client and therapist engagement evolves (social-autopoetically); any
    other external analyses of systems such as of environmental consequences
    that impact client outcomes    
 
    System  from Exterior:  (Intersubjectivity): Interpretive inquiry in
    general (Riouer, Gadamer, Giorgi) including hermeneutic investigations
    of the intersubjectivity/in-betweeness/fit of client and therapist
    (Stolorow et al)    
 
An integral approach to psychotherapy research calls for an integration of research methodologies – honoring the values and limits of each approach – and anticipates that a coherently organized pluralism of inquiries (an “integral methodological pluralism”) will help advance our understanding of psychotherapy process and outcome far more than one narrowly-defined form of empiricism will. Although Hilde Rapp’s writings are among my very favorite on the SEPI listserv, I don’t understand the nature of her “quarrel” with Wilber. As someone deeply familiar with his work, I don’t consider it accurate to say his project is to “unify a universe of discourse” so much as it is to provide a conceptual scaffolding (AQAL) with which many of the parochial and acrimonious debates can be transformed into mutually-enriching dialogues, hopefully facilitating both humility in each camp’s claims to total knowledge and a heightened curiosity about how other perspectives can enrich their own. For example, Wilber’s quadratic model nicely assimilates Hilde’s “four simple distinctions to map the field – each of which connects into a particular tradition of enquiry” (see below). In a similar manner, many approaches that appear irreconcilable (medical and contextual) are, from the meta-perspective of integral theory, not only reconcilable, but mutually enriching.  
 
    The Four Quadrants and Hilde Rapp’s “four simple distinctions to map the
    field – each of which connects into a particular tradition of enquiry”
 
    Individual from Interior:  “I. exploring subjective experience”   
 
    Individual from Exterior: “ III. Examining and measuring bio-social
    determinants”   
 
    System from Interior:    “II. Exploring cultural patterns of meaning
    making”   
 
    System  from Exterior:  “IV. Investigating the effects of
    social-political-environmental-economic regulation of society”  
 
Hopefully the "figures" of the four quadrants reveal that an integral approach (and there is not just one approach to integral; it is a broad framework capable of assimilating and accommodating tremendous diversity) transcend dichotomous positions. No one perspective or methodology is inherently privileged over others in all cases. Yes, one approach may be more appropriate than another based upon developmental issues or a host of other factors (quadrants, lines, states, types, etc.), but no “pure-form” approach or methodology hegemonically dominates within the integral metatheory.
 
I also do not think that all meta-theories necessarily clash with or contradict other meta-theories. Wilber’s integral metatheory (2000a; 2000b) and Mahoney’s constructive metatheory (2004) are illustrative of this. Both Wilber and Mahoney are not only sympathetic to each other’s work, but Mahoney and I (2002) have written together on “Integral Constructivism”, though that article was far from a genuine integration of those two metatheories. Also fundamentally commensurable with those two metatheoretical approaches is the Transtheoretical approach  (Prochaska, DiClemente, Norcross) which is something akin to another metatheoretical approach.
 
To address very briefly Tullio’s initial question regarding why psychotherapists are so much divided, I want to suggest that the very boundaries that separate and divide therapists also connect them simultaneously. Strict empirical methods will never disclose the qualities of lived-experience or what makes a life worth living, just as phenomenology will never reveal the neurobiological underpinnings of our experience. Am I naïve, or isn’t it becoming increasingly clear that our understanding of human nature, psychopathology, and change processes will be increased by a metatheorical scaffolding that honors the validity of different epistemologies, recognizes the limits of each, and provides a systematic way to organize them such that the different approaches synergistically complement, rather contradict, one another? I believe that Wilber’s integral theory is capable of lending a bit more room for, and order amongst, the many differences we find in the field of psychotherapy. Simply consider the differences between radical behaviorism and classical psychoanalysis. Their conclusions were virtually opposite, but what else would you expect when Skinner posited that the only data worth studying are externally observable behaviors and environmental contingencies and Freud was primarily concerned not only with internal experience, but largely unconscious determinants of experience. Skinner privileged looking from the outside; Freud privileged “looking” from within. It’s not that one of them was right and the other wrong. They were both partially correct and both partially limited because they didn’t look at the subject matter from more than one perspective.
 
An article I wrote with Wilber for the issue of Journal of Psychotherapy Integration devoted to unification briefly touches upon some of these issues, though we were asked to keep the article to 5-10 pages, which was quite a challenge. I am beginning to work on a much longer, more detailed article on Integral Psychotherapy and its meta-theoretical approach to psychotherapy integration that I will submit to JPI.
 
 Paul Wachtel, 22 February 2006

Dear Andre,

Welcome to the dialogue and thank you for your stimulating contribution. One question about which I am unclear – what makes the first set of examples of system from interior "interior" and systemic from exterior "exterior"? If anything, I would at least initially think of watching the video tape as "exterior" and interpretive, intersubjective thinking as more "interior. Was there a typo, or am I missing something basic?

I am clearer about exploring cultural patterns of meaning making as in a sense "interior" and investigating the effects of social-political-environmental-economic regulation of society as "exterior."

But finally, as one more difference among us that probably also needs to be taken into account (and, of course, eventually integrated, or at least the attempt made to bridge the dichotomies), I am aware that, although I feel largely in agreement with much of what you are saying, and find some of it extremely perceptive, I am also, by inclination, somewhat suspicious (this is not quite the right word– sounds too hostile; maybe "disinclined toward" or something like that) of schemes that are too abstract. Your illustrations help to concretize. But there is something in the overall scheme that feels like it looks too much at the world from outer space, denoting that, as we mortals clash and bump into each other, we are missing that there is north, south, east, and west (even though, to be strict about it, those axes are more earth-bound than universal in a literal sense). I am deeply committed to theorizing, but I guess a bit more skeptical about "meta" theorizing. It has the danger to me of being a little too up in the air.

But again, that is a matter of taste and style, not a critique. I mention it to alert us to still another way in which we can sail by each other, blithely unaware of other possibilities because they are not coded to appear on our radar screens.

Andre Marquis, 22 February 2006

Dear Paul,

Thanks for your prompt reply. You are correct that I made a typo regarding systems from the interior and exterior (I accidentally reversed them; I apologize for that and appreciate your attending to details). It should have looked as you suspected:

    System  from Exterior:  (Interobjectivity):  Systemic analyses (including    
   videotaped sessions) ala Greenberg's (1999) intensive observation,
    measurement, and analyses of concrete-change performances; as   well how client and         
    therapist engagement evolves (social-autopoetically); any other external analyses of    
    systems such as of environmental consequences that impact client outcomes  
  
    System from Interior: (Intersubjectivity): Interpretive inquiry in
    general (Riouer, Gadamer, Giorgi) including hermeneutic investigations of the       
    intersubjectivity/in-betweeness/fit of client and therapist (Stolorow et al)   

I also appreciate your wariness of overly abstract schemes. Although it may not have been clear in my previous reply, I am committed to theorizing only to the extent that it translates into more effective practice. Of course, there is the matter of how to evaluate if any theory actually improves clinical practice, and that is part of the dialogue that has been taking place throughout the last week on this listserv. That will also be part of my career-long research agenda. There is also the issue of the different ways that theories can facilitate more effective practice (for instance, by changing the therapist, in contrast to changing the specific interventions used).

As I mentioned, many, many of the details of an integral approach to psychotherapy integration (PI) remain to be worked out. And there won’t be just one working out of it. Whether from journal publications that receive critical responses, dialogues on this listserv, my own clinical experiences, or more controlled experimental research, disconfirming details will hasten my accommodating integral theory to “fit with the facts” or “down-to-earth” practicalities of clinical practice. Thus, much of my challenge will involve a delicate balance of what integral theory’s AQAL model can assimilate and how the AQAL model will need to accommodate itself to “fit the facts.”
 
As I have begun to formulate my ideas on an integral approach to PI, I have become aware that a large part of how integral theory can influence the practice of psychotherapy is by changing how one conceptualizes the human condition, the multitude of factors influencing psychopathology and suffering, and comprehensive treatment. Of course, I see other valuable aspects of the integral model being significantly helpful; for example, its encouraging/urging clinicians to deeply train their attention, awareness, presence, and compassion so that their capacity to be with and bear witness to clients’ suffering is enhanced. Which is not to say humanistic encounters are all that is needed; I am a firm believer that compassion and care must be complemented with technical expertise and honed clinical judgement.
 

Tullio Carere, 23 February 2006

Hi Paul,
 
I look forward to discussing the following points over a cappuccino, or a glass of Chianti:
 
1. You think that "the controls of systematic empirical research are very substantially better than the 'discipline' the lone clinician can muster." Better for what? If I had to choose between a therapist with a disciplined mind and one who is perfectly knowledgeable about all systematic empirical research on earth, I would have no doubt and choose the former – wouldn't you do the same? Besides, a man of discipline looks for the company of other men of discipline, just as a man of empirical research prefers the company of other empirical researchers. Discipline of mind is not a matter of lone clinicians, it is an intersubjective enterprise like empirical research.
 
2. You think that I am  "too cavalier and dismissive toward empirical data". In my self-perception I am only dismissive toward the claim of hegemony of empirical data over our field. I believe that it is dangerously reductive to think of psychotherapy as a primarily scientific enterprise (which leads to the dangerous idea that the medical model -- empirically supported manualized procedures to treat specific disorders or meet specific needs -- is a superior form of treatment). In my view psychotherapy is a primarily ethical discipline, inasmuch as both patient and therapist are engaged in a relationship in which they decide at any single step what to do in a relationship involving meanings and values. In an ethical perspective (pre-conventional –conventional –post conventional), empirical science and even randomized clinical trials have their own place. A manual is better than arbitrariness, as the capacity and the responsibility to choose the right thing to do in the unique circumstances of a psychotherapeutic encounter is better than any manual.
 
3. In an ethical perspective -- in which manualized and truncated treatments can be the right choice for inexperienced therapists and low-budget public services, as well as for the conventional side of all of us -- the aim is to progress from a conventional (school based, theory and protocol driven) to a post-conventional, genuine therapy, in which the interaction between patient and therapist is less and less ruled by theories and protocols, and more and more guided by dialogue and moment by moment assessment of whatever the process requires of both members of the therapeutic couple. Technical procedures have their place here too, but in a heuristic, not a stereotyped mode ("the experience of the community to which I belong and my own tell me that a given procedure could be useful in similar cases: let us see what happens if I try it here, how it will be experienced be my patient and myself in this specific circumstance").
 
4. In genuine, predominantly post-conventional, dialogical therapy a scientific approach is essential, but not in the form of the application to the interaction here and now of some guidelines that some empirical researchers have concocted there and then. The dialogic therapist is primarily a local scientist (in dialectical tension with the local artist - the dialogic therapist being in fact a dialogic-dialectical therapist). It means that the therapeutic relationship becomes the laboratory where all sort of hypotheses relevant to the present case are formulated, discussed, and tested in a variety of ways by a couple of local scientists (the patient is co-opted as an assistant). Besides, the two scientists produce documents (particularly in the form of recordings of the session or post-session questionnaires) for monitoring the process and correlating process and outcome. At the level of dialogical, post-conventional therapy the aim of empirical research is not to demonstrate the efficacy of some manualized procedures for specific disorders (the aim of empirical research at the conventional level), but to correlate process and outcome. The process develops in its own, unforeseeable way, what we need to know is to which extent the outcome has been affected by the process. As in the study of all historical process, research is documental, not experimental. And the scientific historian interprets the documents, does not make statistics with them.

Tullio Carere, 24 February 2006

I wrote: "If I had to choose between a therapist with a disciplined mind..". Sorry: I did not mean "a therapist who has fully disciplined his or her mind", nor "one who has approximated that goal to any significant degree", but just "a man of discipline", i.e. a man who has prioritized the discipline of the mind (in the form of epoché, of the noetic/dianoetic dialectic, or else) over the learning of any empirically supported procedure.   

Paolo Migone, 24 February 2006

Dear Tullio,
I have the feeling that to rely on ethics is quite useless, especially today when we are in a multi-cultural, multi-ethnic and pluri-religious age. Everybody knows that a given cultural population may have ethical principles that are considered unethical by others. And everybody knows, as well, that often the therapists who do big technical "errors" o behave unethically (according to other therapists) say that they did the right thing and/or "rationalize" their behaviour.
I think we need to find other ways to deal with the problems you are discussing about.

Tullio Carere, 26 February 2006

David Allen wrote:

<<Don't we all agree that we need both empirical research to reduce the biases of clinical observations AND clinical observations to reduce the inherent limitations of our ability to measure psychological constructs in empirical research?  Not only scientists but patients responding to psychological measurement can deceive themselves as well as others. The two methods of discovery compliment one another to my mind; another example of "both-and" thinking rather than "either-or" thinking.  In the same dialectical vein, of course every "theory of everything" generates a competing theory of everything.  The two of them are then reconciled, generating yet another thesis-antithesis-synthesis.  This is how knowledge grows as we get closer and closer to truth.  I think this is an argument in favor of the genesis of metatheories, not against it.>>

David,

You point to a contradiction of mine. I have been praising a dialectical approach, but then I seem to be non dialectical when I suggest that we could or should move from the ground of endlessly conflicting theories to the non theoretical ground of common/uncommon sense. Let me try to explain. I wrote in a previous posting:

<<In my view nothing is wrong with dichotomies, mostly. To the contrary, dichotomies are there to correct therapists' and theorists' one-sidedness. Behavior therapy was born to expose psychoanalysis' one-sidedness. Insight vs. action therapies is a useful dichotomy, because it exposes the one-sidedness of both. It is good, but not good enough. The really good thing is when someone transforms the dichotomy into a polarity. That is, when someone understands that insight and action are not two definitively and insuperably different things, but the two terms of a "cyclical dynamics", as Paul called it in his pioneering work. This is how dialectics works: the apparent separateness and one-sidedness of the two terms of a contradiction is transcended (aufgehoben) when the relation connecting the two is seen and implemented>>.

How is a synthesis or integration between psychoanalysis and behavior therapy ever possible? Is it a case of "theoretical integration"? No way. How could such incompatible and incommensurable theories be "integrated"? It is impossible. A synthesis is possible, but not on a theoretical ground. You have to look at what happens in practice. A patient came to me a month ago, asking for an antidepressant medicine for his obsessive disorder (he had read of this indication). I replied that I am a psychiatrist, but prescribe medicines only in the context of a psychotherapeutic relationship. He accepted four sessions, to begin with. I gave him a low dose of citalopram. At the third weekly session he came and said that the obsessive disorder had greatly improved, but now he had a painful feeling of loneliness and of being abandoned. He saw that the obsessive disorder was a defense against the underlying painful feeling, which had surfaced thanks to the medicine. He was now willing to work through his feelings, and accepted a three-month contract of psychotherapy.
 
What has happened? Have I integrated psychopharmacology and psychoanalysis? Yes, I have, and successfully. Have I integrated psychopharmacological and psychoanalytical theories? Not at all. The dialectic of acting (not only behaviorally, even pharmacologically) and understanding does not happen on a theoretical, but on a practical ground. The ground of common sense, in fact. The common ground of the basics of experience, where you find common needs, factors, goals, as Hilde put it. Theories usually just clash, very seldom produce dialectical conflicts conducive to some sort of synthesis. Theoretical clash is useful, as I said and repeat. But in order to reconcile conflicts you usually have to move to a different ground.

Hilde Rapp, 26 February 2006

Dear Andre,

Thank you very much for your contribution. I have just come back from working abroad and I  apologize that I don’t have time right now to respond in the way you deserve. 

 I just want to say that I too am broadly sympathetic to Ken Wilber’s work, and indeed I have  been in touch with Mike Mahoney  over some years. I am also  in touch with Don Beck  and Chris Cowan  who are spearheading the successor to the Gravesian project in social psychology,  Spiral Dynamics ( SD). As you know, this model is  extending  Maslow’s hierarchy of needs and specifies needs  in terms of  values on the one hand and life conditions on the other. A few years ago, Don has linked up with Ken Wilber to formulate SDI, the All Quadrant All Levels integration  ( AQAL) you have referred us to . I became interested in these approaches precisely because they   offer meta models  rather than models, and they do so in very useful ways  that ‘chime’ with what I have been grappling with since my Frankfurt School days in the sixties and they also provide a helpful way of mapping   the  bio-psycho-social model  as it is current in medical anthropology and in the health sciences in general in the UK.   Any four quadrant approach, including my own,   is , wittingly, or unwittingly rooted in the ancient fourfold mandalas and coordinate systems  which we find in all cultures across geographies and times… 

 My ‘quarrel’ is only ever about the degree to which a broad approach  becomes a ‘school’ and looses some its openness because language becomes standardised to a certain  extent and the model attracts a ‘following’, even though it was originally designed  to be a shared ground map for  leadership project.  This is often an un-intented consequence of its usefulness and success: not wished for – usually- by the person who has offered  this  particular way of thinking to start with. 

 I am merely passionately advocating for staying open to the future,  remaining  respectful of complexity and  being staunchly modest in the face of  what is unknown and perhaps unknowable. I am wary of being too systematic- precisely because certainty it is alluring and tempts us to wish for  the possibility of a comprehensive model, theory or approach – I am  in the words of the poet John Keats, adviocating for  ‘negative capability’ willing to bear the anxiety of doubts and uncertainty, paradox and complexity… 

 Hence my insistence on integrat-ive- rather than integ-ral,  ad-verb rather than ad-jective… construct- ivist rather than construct- ionist… as they say, in the beginning was the verb, not the noun! 

In other words,  Marx was not a Marxist and Freud was not a Freudian- but both were cutting edge thinkers who changed their mind and outlook frequently as new discoveries were made and new ways of thinking about then became either necessary or attractive – and this is also true of Ken, Don and Mike…, but not always true of how their work is used in the field… 

That having being said,  I too am happy to be an ally, and I am genuine appreciative of the ‘integral’ project  insofar as  I have become familiar with it…

I hope I will find time to respond to your points in a more detailed and specific way…

Allan Zuckoff, 26 February 2006

Tullio wrote:

<<How is a synthesis or integration between psychoanalysis and behavior therapy ever possible? Is it a case of "theoretical integration"? No way. How could such incompatible and incommensurable theories be "integrated"? It is impossible. A synthesis is possible, but not on a theoretical ground. You have to look at what happens in practice>>. 

I believe that in this statement, Tullio has captured precisely the problem with the kind of "meta-theory" described by Andre. Because of the differences in their foundational assumptions (what they take to be axiomatic), there is no common ground on which the theory of psychoanalysis and the theory of behaviorism can meet—much less the theory of behaviorism (which asserts that human behavior is strictly determined by external contingencies) and the theory of humanistic and existential psychotherapy (which asserts not only that human beings are purposeful—of course there have been many efforts, however flawed, to reconcile purposefulness and behaviorism—but that we are capable of freely choosing our actions, in ways that are not subject to causal determinism and thus that render behavior in principle inevitably unpredictable). 

As Tullio argues, what calls for integration in psychotherapy are the various strategies and techniques of intervention/healing—a pragmatic integration. The theories, in contrast, because they are not only incomplete but also false, call not for integration but replacement via rethinking and reconceptualization. The theory of evolution does not represent any kind of “integration” of the previously existing theory of divine creation. 

Yet, this still does not mean that "common sense" is an adequate ground for practice. For thousands of years, human healers stumbled upon various remedies that actually did heal—yet the theories (explanations) of why they healed were completely wrong, and thus healing remained very much a hit-or-miss proposition. It's taken until the modern era for theories (e.g., the microbe theory of contagious illness) to be developed that capture the truth well enough to lead to reliable intervention.  

Unfortunately, when it comes to theories of psychotherapy, I suspect we are still in the equivalent of the pre-modern era. For example, the theories of behaviorism and psychoanalysis, different as they are, both rest on a foundation of Cartesian mind/body dualism. Without going on insufferably, suffice it to say that my intellectual wager is that this dualism is (bluntly put) wrong, and thus that any theory upon which it is founded must be overcome—discarded or, at best (in Tullio’s framework), sublated.  

Praxes are integrated; theories are found wanting, discarded, and replaced. It seems to me that both of these tasks are vital to the continued development of psychotherapeutic healing.

George Sticker, 26 February 2006

My preference is for an assimilative approach to integration, in which a preferred theory is maintained and techniques from other approaches are assimilated. However, the challenge after successful assimilation is accommodation - changing the home theory so that it can accommodate a technique that originally would not have been suggested by it. Is accommodation possible or must the theory be discarded in favor of a synthesis? I don't know, and that is the challenge we face.

 Hilde Rapp, 27 February 2006

 Alan wrote :

<<As Tullio argues, what calls for integration in psychotherapy are the various strategies and techniques of intervention/healing—a pragmatic integration>>.

I agree. For me the question here becomes: what outcome do we seek to achieve?  For the sake of argument, the psychoanalyst might  say that the aim of the therapy- the outcome it drives towards, is that the client should complete the developmental task of  emotionally separating from his/her mother in order to become a viable adult. The cognitive behaviour therapist might reformulate this as  the client needs to learn certain  cognitive behavioural skills which involve the false belief that they cannot function without their mother, the  emotional skill of managing their own emotions, social skill of learning to ring up friends when miserable, practice managing their anxieties when decision making etc etc…The analyst might agree that this is the way forward, but might choose to express the means in theoretically driven different language… and this story could be told with respect to  most approaches current in psychotherapy…

 Past Sepi conferences have demonstrated how good our colleagues are in this sort of exercise in translation, transposition and reformulation.

Alan went on to say:

<<The theories, in contrast, because they are not only incomplete but also false, call not for integration but replacement via rethinking and reconceptualization. The theory of evolution does not represent any kind of “integration” of the previously existing theory of divine creation>>

If we go back to the original meaning of “theory” ( theorein)  in Greek, it means “a way of seeing” , rather than a an body of laws  or relationships which organize a set of systematic observations.  It seems to me that most of our psychotherapeutic ” theories”  function more like values  which organize our preferred ways of seeing- or understanding  the observations, presumed facts, and our relationship to what we know and do in the  complex world around us.  The African philosopher John Mbiti once observed that theories  are stories that help us to cope with our fear of the unknown…

I therefore agree that we are working in a  proto- theoretical space, and I submit that the value of  the kind of  meta-theoretical framework I am proposing is that it can act as a shared ground map which allows us to organize such ‘stories’ in terms of the underlying values and facts   that particular individuals and professional ‘schools’  see  as particularly  helpful for our practice.

Working  integrat- ively  then becomes not the endeavour to seek a synthesis or resolution of differences, but  rather, an effort after seeking an understanding  of how different positions are articulated, what conflicts arise between them and when, where , why and in what context this matters.  

As Andre  pointed out, this is also  the arena  where Spiral Dynamics and Integral Theory  are  making a contribution, not necessarily  specifically to psychotherapy, but to our general understanding of the dynamic evolution and articulation of value systems with proto-theoretical content and how to work with conflicts between them.

After such a ‘diagnosis’  of the actors and positions in a given conflict,  such a meta-framework also allows us to  collect and organize  best practice examples of  how to transform these conflicts in a particular  practical situation where colleagues are at loggerheads about the ‘treatment’ of a particular client or patient.

The journal of Psychotherapy Integration  is full of such  best praxis examples- and George has contributed many – and indeed our SEPI conferences are always an exercise in  conflict transformation in action. Of course there are entrenched conflicts for which we have not found  a process, or perhaps we haven’t tried yet…

Allan Zuckoff, 27 February 2006

George wrote:

<<My preference is for an assimilative approach to integration, in which a preferred theory is maintained and techniques from other approaches are assimilated. However, the challenge after successful assimilation is accommodation - changing the home theory so that it can accommodate a technique that originally would not have been suggested by it. Is accommodation possible or must the theory be discarded in favor of a synthesis? I don't know, and that is the challenge we face>>. 

I think this model, drawn as it is from Piaget’s model of individual learning, provides an appealing account of the process of the (ideal) individual practitioner. For anyone who is plying his/her trade as a psychotherapist, challenges will arise that cannot be neatly fit into one’s existing sense-making structure; whereas the rigid therapist rejects the apparent anomaly and insists upon forcing the new challenge into his/her procrustean theoretical bed, the open therapist acknowledges the poorness of fit and adapts to the novel circumstance.  

But, how much do practitioners’ “theories” change, as opposed to their praxes? If I am a client-centered therapist and I notice that whatever client speech I empathize with occurs more frequently, how likely is it that I will conclude that my empathy is merely (and mechanically) reinforcing the client for certain verbal behaviors? I think it’s more likely that I will conclude that I am empathizing accurately, inviting the client to explore more thoroughly that area of his/her experience, and perhaps incorporate the idea that I can guide my sessions towards deeper exploration by empathizing more actively. Because client-centered and behaviorist theories offer not just different, but mutually exclusive accounts of why people act the way they do—and once I buy into the theory of reinforcement, I’m forced to admit that I’m not eliminating conditions of worth but merely changing them into more benign versions.

Thus I’m not sure the assimilative model does the job from the standpoint of the theoretical development of the discipline. This is essentially a model of “normal science” in Kuhn’s sense: when a widely-accepted theory provides the foundation for a great deal of new knowledge discovery, it is maintained via small accommodations. But if our field is still pre-paradigmatic—driven by incompossible theories—then I think what is needed may be more “philosophizing with a hammer.”

Allan Zuckoff, 27 February 2006

Dear Hilde,

 I find much of what you propose helpful to my own thinking about these matters.

The statement that <<most of our psychotherapeutic ” theories”  function more like values  which organize our preferred ways of seeing- or understanding the observations, presumed facts, and our relationship to what we know and do in the  complex world around us>> captures something important for me, going directly to my sense of a disconnect between what we normally mean by the term “theory” and the way that “theories” seem to function in the work of practitioners.  

Yet I also wonder whether the theories themselves—psychoanalysis versus behaviorism, say—are so readily integrated as your example suggests. The behaviorist may admit that the source of a dysfunction lies in the early history of an individual—presumably the occasion of the “false belief that they cannot function without their mother”—but will also insist that the belief was established via reinforcement patterns that have presumably continued to obtain. The psychoanalytic claim that, say, the “belief” is grounded in fixation of cathexes will presumably be given short shrift. So I believe that what you have successfully re-languaged remains at the level of praxis, rather than of theory.  

I also remain uncertain about the value of “meta-theory” in the sense you are describing. In the beginning of The Order of Things, Foucault quotes a story by Borges, in which a certain ancient taxonomy goes something like this (I paraphrase broadly, and with apologies): a) Solid things b) heavy things c) things that belong to the emperor d) things that from a distance look like a chicken…  

Foucault’s point, of course, was that the conceptual space within which such a taxonomy could be comprehended no longer exists, and is so foreign to our own as to render those letter labels [a), b), c)] absurd to us. However, unlike Foucault, I would want to argue that this taxonomy is not merely the product of a different “episteme,” but an inferior one. Because if knowledge does not progress, but merely changes, then we are all absurd. 

My concern about the “metatheoretical space” defined by Andre is that it is uncomfortably like Borges’ taxonomy, and I’m not sure what is gained by placing conflicting constructs in a defined order, or within a single plane. While I see the value in trying to draw out commonalities among competing theories, once again at the level of praxis, I don’t think we will achieve maturity as a discipline until we are precisely able to achieve, at the level of theory, “a synthesis or resolution of differences.” 

David Allen, 27 February 2006

I completely disagree that there is no common grounds on which the theories of psychoanalysis, psychopharmacology, behavior therapy, cognitive therapy, humanistic therapy and family systems theories can meet.  In my opinion, it only appears that way if one views these theories as monolithic wholes that must be accepted or rejected in their entirety, and conceptualize the various theories based on the arguments of each theory's most extreme, reductionistic adherents.  Each theory is in fact a collections of ideas with common threads that are then applied to various observed phenomena in an attempt to understand them.  Some of the conclusions based on theory may be right while others completely wrong.  

No behaviorist I know thinks that human behavior is ONLY determined by external contingencies.  They just choose to intervene there.  Social learning theorists even look at the interpersonal environment, although they do so in an un system-atic way (if you'll pardon the pun).  Likewise, you don't have to believe that OCD is caused by harsh toilet training (an empirically disproved idea from analytic theory) to believe in the general validity of the concept of defense mechanisms (even if you call them mental schemas or automatic thoughts).   

Tullio, you could in fact approach what happened with your obsessive patient using a theoretical integration of pharmacology and psychotherapy, such as a stress-diathesis model.

Hilde Rapp, 27 February 2006

Dear Allan,

 Thank you. I agree with most of what you say, which suggests to me that I have – as  I do from time to time- left out parts of the argument because they are  too familiar to me by now. 

 Yes,  I agree that the potential  accommodation between the  caricatured analyst and  behaviour therapist positions is entirely pragmatic- they would agree on what needed to be done, but they would go about it by different methods/techniques and  they would justify  what they do  differently-  ie take recourse to different  as well as- usually-  incompatible theories. The  proposed common ground is  purely functional. 

In a previous mail to Andre I voiced similar concerns to those advanced by you, although less eloquently and explicitly. Tongue in cheek:  fuzzy semantics are useful to a degree, but beyond that they become woolly ! Even in a scenario where we  could ever  work in an “integral” manner,  sufficiency would  increasingly work against transparency and one would need  an international mainframe collaboration to work out a therapeutic algorithm!  In any case, temperamentally,   I would probably always have  an aversion to any approach that is potentially totalizing- Bob Niemeyer made a very good case about this some years ago, reminding us of an attempt by Goebbels’ cousin to create an integrat-ed psychotherapy in Nazi Germany… 

So,  my  integrative framework should perhaps be simply called a meta-framework rather than a meta-theoretical framework? It transcends theories in so far as it does not  aim to integrate them but merely  to organize them.  Its purpose is to give us a shared ground map which allows us to map or locate theories with respect to their  central focus: does the theory focus  most strongly on subjective experience ( Q1) , does it focus on culturally situated inter-subjective dialogue ( Q2) , does it  aim to organize  on neuroscientific and cognitive-emotional- developmental research findings into new understandings of the human mind/psyche? ( Q3) , or does it focus on   the socio-economic, environmental and political determinants of  mental ill health  ( Q4)  or, to be more specific,  does it look at sociological factors  from a hermeneutic  position ( say Foucault,  then it would be Q2 &Q4) or more from a positivist position ( empirically grounded, drawing more on quantitative studies, say evolutionary theory) then it would be located across  Q3&Q4…    

The purpose of such a mapping would be to explore  along which axes of enquiry the major conflicts lie  with a view to learning something from each other without giving up our positions if the approaches look like they are too incompatible. This would be to advance academic enquiry and practical skill and knowledge building  and CP/E/D. 

Or more practically still,  we might want/ need to transform a conflict between colleagues with shared responsibility for a shared patient or client- Tyler’s issue, for example – this would be leadership and conflict transformation work. 

 What we tend to learn by using a meta framework approach  and we  can tolerate, nay, embrace difference and healthy competition, is usually a new technique which borrow and assimilatively integrate into our own approach. 

 What we are invited to let go off is our fear of difference, our competitive desire to win, and our discomfort in the face of not knowing and  our anxieties about not being in control… 

Tullio Carere, 28 February 2006

Paolo Migone wrote:

<< Dear Tullio, I have the feeling that to rely on ethics is quite useless, especially today when we are in a multi-cultural, multi-ethnic and pluri-religious age. Everybody knows that a given cultural population may have ethical principles that are considered unethical by others. And everybody knows, as well, that often the therapists who do big technical "errors" o behave unethically (according to other therapists) say that they did the right thing and/or "rationalize" their behaviour.
I think we need to find other ways to deal with the problems you are discussing about >>.

Dear Paolo,
Do you really believe that we can leave ethics out of the door? Ethics is the study of how we decide that a choice is good or bad, right or wrong. Psychotherapy is ethics, from start to end. In an era dominated by the myth of science many people believe that science is neutral, i.e. not grounded on ethical and metaphysical choices. Modern epistemology has dismantled this myth (even Popper had to grudgingly admit it, in the end). For instance, the evidence based psychotherapy is based on the belief that you can extract a procedure from the relationship in which it is embedded, and administer it to a patient in the same way as you administer a drug. You choose to believe that psychotherapy works like medicine, and you produce empirical data to support your belief. You can produce empirical data to support almost any belief (even the belief in miracles: at the Vatican they have a scientific faculty for that). 

In ethics you have three levels. At the ground level (preconventional) you are the lawmaker: you decide what is right or wrong, you don't care what other people think. At the second floor (conventional) you submit to some conventional law: you are the follower of some school or theory, you behave according to the principles of your convention -  for instance, you administer protocol driven procedures. At the third floor you suspend as much as you can all your presuppositions and expectations; you try to understand what every individual situation requires, and behave accordingly; in the awareness that your perceptions and evaluations are limited and fallible, you constantly look for feed-back, dialogue and confrontation. All three levels are present in different proportions in most of us. Genuine dialogue happens at the third floor. Faith in dialogue (dia-logos) is the belief that you can move in life (and in therapy) beyond all conventions, guided by the inherent logic of any process (the logos) that manifests itself in the relationship between (dia) people willing to let go of any preconceptions and expectations to open up to it. 

Hilde Rapp, 28 February 2006

Dear Tullio, dear Paulo,
 In haste:  perhaps it would help to distinguish between ethics and morality on the one hand and  religion and spirituality on the other.
 Crudely, by rule of thumb:  ethics  relates to principles of natural or distributive justice, while morality relates to conforming to the rules and codes of conduct that are the norm ( conventional) in a given cultural reference group.
In a similar vein, spirituality relates to principles that help us to establish a relationship to the Sacred ( Divine to some)  as such and  in ourselves and in our fellow living beings ( by whatever name or none), while religion ties us into sets of beliefs and rituals which constitute a particular theology and   faith based practice…
 
While morality is grounded in ethics and religion is rooted in spirituality,  a person can act ethically and yet contravene  prevailing moral dictates ( a white person having relations with a black person in Apartheid South Africa, which would have been illegal to boot!), just as a spiritual person may be burnt at the stake for heresy…
 
Having said that I agree with you Tullio, that psychotherapy is a profoundly ethical practice, and- if I read you correctly- I agree with you Paulo, that morality has no place in it- other than as information about what the client believes or what she might be  up against!

Allan Zuckoff, 28 February 2006

Dear Hilde,

Thank you for taking the time to lay out your argument more explicitly; it seemed very clear, even in pre-edited form. I do think that we agree on many things, although I’m not at all daunted by the prospect of a “totalizing” theory of psychotherapy—in fact, I think that should be our goal (just as a “unified theory” is the goal of physics), but I’m certain that the approach to such a theory (for such finite creatures as ourselves) will be asymptotic.  

Your “meta-framework” sounds like it is organized to lead to the overcoming of conflicts among theories via higher-order syntheses, though without demanding that adherents give up their individual theories until they are ready to do so. More than anything, this seems like a skillful therapeutic intervention for academics: invite them to relax their defenses enough to consider other perspectives, but avoid generating resistance by not trying to strip those defenses away?

Allan Zuckoff, 28 February 2006

David,

I certainly agree that, in practice, adherents of competing theoretical schools borrow from other schools and reject aspects of their own. But I disagree with your definition of theories as “collections of ideas with common threads that are then applied to various observed phenomena in an attempt to understand them.” I understand theories as well-organized explanatory frameworks, which can be applied to a range of phe