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, Ken Benau, David Allen, Andre
Marquis, Paolo Migone, Stephan Tobin, Barry Wolfe, Zoltan Gross,
Luca Panseri, Mike Basseches.
Dear colleagues and friends,
I have asked all the presenters at the Florence SEPI Conference (March
24-26, 2006, http://www.vertici.com/sepi/ ) to shortly comment on a few questions that roughly describe our
topic. Here are the questions:
Dealing with integration means to deal with what divides the psychotherapists.
Why are psychotherapists so much divided, in comparison to cardiologists
or endocrinologists? Maybe because psychotherapy is not a science?
Or because, as some maintain, it is not yet a
science, but it will become one when psychotherapists will decide
to submit to the rules of all good science, from physics upwards,
getting out of the medieval darkness like all other branches of medicine?
Or rather because psychotherapy is not at all a branch of medicine?
Shall we admit that there exist two quite different practices, one
of medical type, based on psychopathological diagnoses and empirically
supported therapeutic procedures, the other of humanistic type, in
which the meaning of the disorders and of the ways to cure them does
not come out of diagnostic and therapeutic manuals, but of therapeutic
dialogue and context? In that case, shall we surrender to the irreducible
diversity of the two approaches, acknowledging that treating a patient
is incomparable with caring for a subject, or shall we understand
them as the two terms of a polarity, inside which every therapist
can conveniently locate himself or herself according to temperament
and preferences?
I hope
some of you will want to join us in the discussion on this listserv.
Paul Wachtel, 22 January 2006
In my own view, the matter is not as dichotomous as it can seem to
be in some interpretations of the questions posed. I do not
think that our divisions are easily explained in terms of simply whether
we are a science or not. I say this in part because I think
that the term "science" itself is – or should be – a manifold
term, not a singular, prescriptive term. I say it as well because
some of the divisions, some of our difficulties in achieving consensus
are due to the subject matter of our science being extraordinarily
ambiguous and difficult to address in very general ways rather
than it being intrinsically inaccessible. (They also
derive, as I shall comment on shortly, from the very strong connection
of our particular subject matter with values and identity).
To begin with science: To my mind the essence
of the scientific method is to take seriously the very things that
we, as psychotherapists, particularly should understand. That
it is very easy to deceive ourselves, that our memories are suspect,
that it is hard to hold onto very much without recording it systematically,
that our very perceptions are subject both to motivated and to unmotivated
skews and distortions. The scientific method – no, I am already
slipping into a singular when it should be a plural; scientific methods
are that quite considerable variety of ways in which we try to
minimize or reduce those effects (we can never eliminate them,
only reduce them).
The problem is that we almost have a variant
of the Heisenberg principle operating – not so much in terms of our
role as observers changing what we observe (though that, of course,
is also true), but in terms of the tradeoff that is entailed.
In quantum physics, the more we know about the position of a
particle, the less we know about its velocity and vice versa. The
very knowing of one reduces our knowing of the other. In psychology,
the tradeoff I have in mind is a little different. It is that
the more precisely we know something, the more we can use "traditional"
scientific methods, often the less useful or comprehensive or directly
applicable is that knowledge.
This is not quite as airtight as it is in
quantum physics, which is why I said "almost" a variant
of the Heisenberg principle. Sometimes, very precise experimental
studies are about very crucially important things, and the refusal
to acknowledge that can be a rationalization for laziness or for continuing
to do what one is used to rather than responsibly paying attention
to the evidence. But all in all, the tradeoffs are significant.
The kinds of phenomena that psychoanalytic therapists and theorists
are interested in, for example, the subtle issues of affect, conflict,
motive, the concern with the edge of experience, with what is not
yet expressible, etc – these are hard to address with traditional
experimental studies (though even here it is important to acknowledge
that some very important work has been done in this regard).
I do believe that sometimes we parrot the
models of physics, say, or of medicine, to the detriment of our discipline.
We need to find the kinds of disciplined observations and systematic
recording of data that are appropriate to the questions we are asking.
At our present level of knowledge, for example, one of the technologies
that is most relevant is the by now humble one of video and audiotape
recorders. This permits several extremely important things to be added
to what Freud, say, was able to see, remember, and check on. First,
and very important, it allows others to see the same material (though
there are of course differences between seeing a tape and actually
being there in the affective field with the patient – no solution
is perfect). Second, it permits the therapist him or herself
to check on what has been remembered. It is striking
how different a sequence can be when one watches it on tape from what
one has remembered (and the subtle differences are just as important
as the dramatic and obvious ones). Third, sometimes we only
see something that has, in essence, been lying there waiting
for us to notice, after looking at it many times. In one of
my very first published papers, concerned with what is communicated
by body language, I described a pattern I did not see until I looked
at the tape an enormous number of times. But once I finally
noticed it, it "jumped out" at me and became rather obvious.
This is just one example of a "scientific"
advance over just reporting what one remembers from one's sessions,
often at the end of the day or even days or years later looking back
on the case. I mention the tape recorder precisely because (a)
these days it is a rather humble instrument, available to most children
let alone adults, and yet it is something that Freud simply could
not conceive would be available to psychoanalytic research; (b) it
is a method that basically retains the usual focus of the intensive
psychotherapist. That is, it simply records the effort to be
empathically attuned to the patient's affect state, etc, rather than
diverting that effort. It still requires a good deal of inference
and interpretation to maintain certain views, but the argument has
a somewhat more solid foundation. (Some people argue that to
record a session totally changes the configuration of what is transpiring.
I believe that to be a self-serving rationalization for not
exposing either one's clinical skills or one's ideas to this kind
of scrutiny.)
More complicated or technologically advanced
ways of improving on what we can know just from sessions are, of course,
also available, often in the form of some kind of physiological or
neurological recording, but consisting of many other methods as well.
There, we quickly find ourselves on the slippery slope of tradeoffs
I referred to above. But although we may not be able to completely
resolve that dilemma, I believe we do a better job of zeroing in on
what we need to know by shifting back and forth to some degree from
one end of the tradeoff slope to the other. That is, sometimes shifting
away from our "intuition" toward considering what a particular
experimental finding suggests, even if its ecological validity can
be in question; sometimes, shifting away from what the "findings"
are that seem to emerge from certain studies because one is paying
attention to what one's affects, interpersonal and empathic connections,
etc are telling us. After all, Luborsky has shown that usually
the researcher's own orientation comes out ahead even in carefully
conducted studies of therapy that seem "objective."
Giving credence to what the physicist and philosopher Polanyi
called the "tacit" dimension or tacit knowledge is an important
corrective to ideologically driven scientism.
So again, in my view, the biggest problem
is falling into an either-or dichotomy. And, in my view, there
is a danger that the seemingly ecumenical "both-and" stance
can itself be an unwitting falling into dichotomy because it implies
that the two sides being equally considered and valued are two totally
different sides.
So, to return to the main set of questions,
I do not think " there exist two quite different practices,
one of medical type, based on psychopathological diagnoses and empirically
supported therapeutic procedures, the other of humanistic type."
And I say this even though I am a very strong critic
of the ideology that "empirical validation" means manuals.
In my work with patients, and in my theorizing, I sometimes
am going along paying attention to my subjective experience of being
with someone when a "finding" occurs to me that alters what
I am doing and how I am seeing and experiencing what is going on between
us. And in my reading of the research literature, I am attentive
to the methodology, and (apropos what I just said) am seriously respectful
of the content of the findings, but I am also simultaneously thinking
about it in terms of what my experience in life has been of what it
is to be a human being, to be in a relationship with another person,
etc.
I guess maybe that is why I am a SEPI person.
I am not a dichotomist by and large (you could certainly
find some places where I am, especially in the realm of politics).
I tend to look at both sides not just in terms of theories (psychodynamic,
cognitive-behavioral, family systems, experiential, etc.) but also
in terms of methodologies and perspectives (empathic immersion, controlled
experiments, etc.)
Tullio Carere, 23 January 2006
Dear Paul,
thank you for your precious response. As you begin by saying "In
my own view, the matter is not as dichotomous as it can seem to be
in some interpretations of the questions posed", I want to clarify
that in my view the scientific-humanistic dichotomy, before being
a matter which one can approve or disapprove of, is a matter of
fact. I often cite B. Carey's incipit of a noted NYT 2004 article
that depicts the way the world looks at us:
Good therapists usually work
to resolve conflicts, not inflame them. But there is a civil war going
on in psychology, and not everyone is in the mood for healing. On
one side are experts who argue that what therapists do in their consulting
rooms should be backed by scientific studies proving its worth. On
the other are those who say that the push for this evidence threatens
the very things that make psychotherapy work in the first place.
If we acknowledge this fact in the
first place, what follows next is what we decide to do with it. We
can consider it as just the result of a simplistic attitude in our
field regarding the scientific method (or methods, as you say and
I agree), and the difficulty to understand the extraordinary ambiguity
of our subject matter. Or, beyond that, we can see in the split of
our field the reflex of a contradiction that has not yet been dialectically
articulated, and is consequently stuck in a sterile opposition. As
you fittingly observe,
<<The problem is that we
almost have a variant of the Heisenberg principle operating – not
so much in terms of our role as observers changing what we observe
(though that, of course, is also true), but in terms of the tradeoff
that is entailed. In quantum physics, the more we know about
the position of a particle, the less we know about its velocity and
vice versa. The very knowing of one reduces our knowing of the
other. In psychology, the tradeoff I have in mind is a little
different. It is that the more precisely we know something,
the more we can use "traditional" scientific methods, often
the less useful or comprehensive or directly applicable is that knowledge>>
I am struck by you reference to
the indetermination principle, because I myself am working along
the same line. My own formulation of that principle, applied to
our field, is: The more objectively we want to know the phenomena
happening in a therapeutic relationship, the more the subjective
side of the same phenomena - emotions, meanings, values - eludes
us, and vice versa. The unawareness of this principle is in
my view the basic cause of our "great divide". At the
two sides of the divide stand respectively those who privilege objectivity
(therefore aiming at a psychotherapy akin to medicine, in which
disorders are identified through diagnostic manuals and treated
by means of empirically supported procedures), and those who privilege
subjectivity (therefore being little interested in diagnoses and
procedures, but much in the emotions elicited and the meanings made
or uncovered in the process).
To heal the split means to me to recover a dialectic of the subject
and the object, transforming the dichotomy in a polarity in which
neither term is privileged a priori. The implications for research
are far reaching. On one side traditional psychoanalytic research,
which considers only subjective data, on the other empirical research
(especially the one of randomized clinical trials), which is only
interested in reproducible and measurable data, have produced a
situation of impasse and reciprocal incompatibility. I believe that
the impasse can be overcome starting from two basic points.
The first is the acknowledgment by the therapists of the necessity
of documenting their work not just with clinical notes, but also
with audio- or video recording (as you prefer) or post-session questionnaires
(as I prefer). In this way the object of study is real therapy,
not a laboratory artifact, and the data obtained are of a documental,
not experimental type. The second point regards the way of
processing the data. The data of a process, be it of historical,
juridical, psychological or narrative nature, do not lend themselves
very much to mathematic-statistical processing: what they essentially
need is interpretation. Basically, to overcome the subject/object
dichotomy a research in psychotherapy should integrate the therapist's
interpretation of whatever transpires in the session (subjective
data) with the interpretation of process documents (objective data).
This is what I do in my minuscule research group, and what in my
view every single therapist could and maybe should do, in the spirit
of the Freudian Junktim: the inseparable connection between theory,
practice, and research.
Thank you again, Paul, for your contribution to our pre-conference
discussion (I have forwarded your text to the Italian conference
discussion list), and especially for your reference to the indetermination
principle (almost).
John
Norcross, 24 January 2006
To understand the psychotherapies,
one must appreciate both the robust commonalties that unite
them and the enduring differences that separate them. To appreciate
only the undifferentiated, lowest-common denominator mass is to miss
the clear distinctions among component parts. To appreciate only the
precise distinctions of the components is to miss the larger gestalt.
We should strive to integrate the differentiated parts into
the whole at a higher level. Here, we can understand the unity
and the complexity of psychotherapy. It is to this level,
I believe, that psychotherapy should aspire.
In clinical work, we can combine the power
of the common factors and the specificity of the differences. In fact,
many of the differences among the psychotherapies are complimentary
when working with patients. Disparate treatment content and
goals of the psychotherapies, for example, can be prescriptively matched
to the clinical needs and treatment preferences of individual patients.
Different psychotherapeutic methods have been shown to be differentially
effective for patients in different stages of change, for another
example. The insight-oriented and motivation-enhancement methods
are indicated for patients in precontemplation and contemplation stages,
while more cognitive and behavioral methods are indicated for patients
in the action stage. And highly directive and paradoxical methods
have been shown to be more effective for high-resistance patients,
for a third example. Different strokes for different folks.
Finally, I am deeply concerned about the tendency
to bifurcate the field of psychotherapy into bipolar camps: insight
vs action therapies, objective vs. subjective therapies, or, as implied
in the stimulus question, medical model vs. contextual model. It
serves neither our discipline nor our clients. The alternative is
not to deny real differences; the alternative is to
avoid dichotomous experiences and to appreciate both the unity and
complexity of psychotherapy, using the real differences to enhance
outcome by tailoring psychotherapy to the individual client and the
singular situation.
Tullio Carere, 25 January 2006
Thank you John for sharing with us your deep concern "about
the tendency to bifurcate the field of psychotherapy into bipolar
camps: insight vs action therapies, objective vs. subjective
therapies, or, as implied in the stimulus question, medical model
vs. contextual model", and your belief that "it serves
neither our discipline nor our clients", coupled with the
belief that "the alternative is to avoid dichotomous experiences
and to appreciate both the unity and complexity of psychotherapy,
using the real differences to enhance outcome by tailoring psychotherapy
to the individual client and the singular situation."
I myself am a believer in the unity and complexity of psychotherapy
(although I do not believe in the uselessness of the bipolar perspective).
Of course you are aware that we live in a world of infidels who don't
believe in the unity of psychotherapy. For instance, in psychoanalysis
the believers in a common ground are called the "common grounders"
and are said to be one of the five or six major psychoanalytic tribes
living in a reserve, watched over with suspicion or open hostility
by all the other tribes. According to the First Law of Discussions
among Psychotherapists, whenever a psychotherapist says that psychotherapy
has the X property (e.g., it has robust commonalities), there always
is another therapist who says that his or her thing does not
have the X property (e.g., there are at most family resemblances).
Our field produces dichotomies as other fields produce daisies. But
it seems to me that there are many more people allergic to dichotomies
than to daisies.
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. In the
same vein, the current dichotomy between practice and research can
be transformed into a polarity if the two are no longer seen as two
separate things made by different operators with different competences,
but as the two sides of an integrated enterprise, as I have tried
to sketch in a previous posting.
I stop here, because allergy to dichotomies is nothing, compared to
the almost anaphylactic crises unchained by dialectics in some friends
and colleagues, and I don't want to stress their immune system.
George Stricker, 25 January 2006
I'm not sure that John and Tullio really disagree,
but whether they do or not, let me indicate where I stand on this.
I agree with John that the creation of bipolar camps is not constructive,
and often the polarities are given life and exclude the other. However,
I agree with Tullio as to the value of a dialectic process, and that
begins with opposing views that then can be reconciled for a higher
order solution (which, in turn, gives way to further opposition and
resultant syntheses, in a continuing process). As for science and
practice, my views are in my writing on the Local Clinical Scientist,
a formulation that has the clinician acting as a scientist in a laboratory
with the patient, maintaining attitudes of skepticism and inquiry,
and learning from each encounter. This requires the systematic record
keeping that Tullio discussed earlier in order to be effective.
Allan Zuckoff, 25 January 2006
Dear Tullio,
I’ve enjoyed reading this exchange, and have been glad to see a
reemergence of substantive discussion on this listserv. I join the
discussion as a psychologist trained in empirical-phenomenological
research methods who has spent much of the past decade involved
in controlled trials of psychotherapy interventions, and thus as
someone who has sympathies for both sides of the dichotomy (or poles
of the dialectic, if you prefer).
In one of your posts to Paul, you wrote:
<<I believe
that the impasse can be overcome starting from two basic points.
The first is the acknowledgment by the therapists of the necessity
of documenting their work not just with clinical notes, but also
with audio- or video recording (as you prefer) or post-session questionnaires
(as I prefer). In this way the object of study is real therapy,
not a laboratory artifact, and the data obtained are of a documental,
not experimental type.>>
I agree that the object of psychotherapy research should be, as
you put it, “real therapy.” I gather, though (based on past listserv
posts), that you do not consider time-limited, protocol-guided therapy
provided in the context of a research study to fit that description.
If I’m correct in this understanding (and I apologize in advance
if I have misconstrued you), then this is perplexingly dismissive
of the powerful effects such therapies have been repeatedly demonstrated
to have (as well as of the “reality” of the therapeutic encounters
I have experienced in doing such therapies). It would also deprive
us of excellent sources of the data that I think interests both
of us the most: live, meaningful interactions between therapist
and client.
Relatedly, I am also perplexed by your suggestion of an equivalence
between recordings of therapy sessions, and post-session questionnaires.
From an empirical perspective, research on training of therapists
in motivational interviewing (the area with which I am most familiar)
has shown that the gap between what therapists think they are doing,
and what recordings show them to have been doing, is rather substantial
(especially with regard to expressed empathy). From a psychoanalytic
perspective, this should hardly be surprising: no matter how well-analyzed,
therapists have their defenses, and their own assessment of what
has happened and what they have done in a session should reliably
be expected to be distorted in various ways. For access to the rich
intersubjectivity of therapeutic process, it seems to me that there
can be no substitute for recording of sessions.
I’ve chosen to address two of your specific points, rather than
the overarching theoretical and conceptual issues, because I think
it’s in such points that the challenges of psychotherapy integration
become most clear. If agreement is impossible on points such as
this, then it’s hard for me to see how the rifts you have highlighted
can be healed. If synthesis can be achieved on such questions, however,
perhaps there is more hope.
Hilde Rapp, 26 January 2006
Tullio observes/ asks:
<<Dealing with integration means to deal with what
divides the psychotherapists. Why are psychotherapists
so much divided, in comparison to cardiologists or endocrinologists?>>
All knowledge, as Bion so astutely observed,
requires linking that which is similar and separating that which
is dissimilar or different – all thought and all language depends
on making distinctions. Psychotherapy has in common with the natural
sciences that part of the activities of practitioners of psychological
therapies consist in observing the client’s behaviour, noticing
regularities or patterns, and finding ways of systematizing these
observations through description, where possible measurement, and
through searching for regularities and consistencies in
the relations between observations – something akin to formulating
rules, laws and theories. Psychiatric classification depends
on such systematizing work, including certain behaviours, signs
or symptoms in the description of clients disordered thoughts,
feelings and behaviours and excluding others in
order to arrive at a differential diagnosis.
Psychotherapy is dissimilar from the natural sciences
and similar to the Geisteswissenschaften ( sciences of the
mind – what anglosaxons call Human sciences and the arts),
in that it also enquires into subjective and cultural acts
of meaning making by exploring with clients through questioning
and spontaneous self report , their own efforts after assigning
meaning and significance to the content of their consciousness.
This activity draws on culturally mediated symbols and metaphors
as well as subtle distinctions between affect states such
as regret, remorse, repentance, shame or guilt and culturally
mediated story grammars or forms of narrative. The negotiation of
such intersubjective meaning and perhaps even transpersonal
experience can be tapped by methods of measurement as for instance
in discourse analysis, both of key words and of non verbal signs,
such as hesitation patterns, inflection and so forth. More usually,
therapists draw on their own capacity for artistic appreciation
and, significantly, for empathic understanding of the client’s
communications, whether verbal or nonverbal, whether in the
form of reports of dreams and fantasies or of reports
of social or natural events, in ways akin to those used by writers,
poets, dramatists, film makers and visual artists.
Tullio poses the questions:
<< Maybe because psychotherapy is not a science? Or
because, as some maintain, it is not yet a science, but it will
become one when psychotherapists will decide to submit to the rules
of all good science, from physics upwards, getting out of the medieval
darkness like all other branches of medicine? Or rather because
psychotherapy is not at all a branch of medicine?>>
I largely agree with the points already
made eloquently by Paul and by John. Although these questions are
common, and although I very much like questions, I do not
think that we should be seduced into providing dichotomous
answers!. As you will see from my contribution to the conference
which also reflects the structure of my forthcoming
book, my understanding of integration depends on respecting
that human beings have only partial access to what may be
known about ourselves and the world. We do not have
a coherent theory of everything- and, Wilber not withstanding, in
some ways I rather hope we never will. Furthermore, we are
prisoners of language when it comes to what can be said about
what we know, and therefore we express what we know according to
different traditions of enquiry. Paradigms, epistemologies and
traditions arise in ways that are the best fit for the purpose
of examining, describing, measuring or classifying the phenomena
we wish to understand at a given time in history. Each age brings
revisions, redecisions and innovations, some clearly advances, others
cul de sacs born of fad or fashion – whether often only time can
tell which is which.
In my view the task of integration is to establish correspondences
or links between the way we describe ( what we hope is) the
same phenomenon in one paradigm and how we describe it in another.
.
I use four simple distinctions to map the field- each of which connects
into a particular tradition of enquiry:
I. Exploring subjective experience
II. Exploring cultural patterns of meaning making
III. Examining and
measuring bio-social determinants
IV. Investigating
the effects of the social-political- environmental- economic
regulation of society
For instance: We may become curious about
correspondences between physiological events such as hormone function,
brain transmitter activity ( III) and thoughts, feelings,
dreams or motivational events etc ( I ). We may want to track such
patterns, insofar as we understand them through the life span- how
do they change with age and experience (III) ? Whatever we do will
be subject to interpretation (I), and our interpretations of any
findings are culturally situated (II). Furthermore, they tend
to have political implications, in that moneys will be allocated
( or not) to research further, and recommendations will
be made via guidelines to regulate access to treatments
or resources (IV). Integrative therapists need to negotiate the
different ways in which communities of enquiry, meaning, interest
or practice use epistemologies and language to share their
knowledge and also to mark it off from the discourses of other disciplines
with a related but different focus of enquiry. This requires adopting
a meta-perspective and , alas, a good deal reading and thinking
outside the box without loosing one’s humility in the face of the
complexity of what we are trying to understand, and crucially to
apply to responsible practice with often vulnerable clients.
Tullio asks:
<<Shall
we admit that there exist two quite different practices, one of
medical type, based on psychopathological diagnoses and empirically
supported therapeutic procedures, the other of humanistic type,
in which the meaning of the disorders and of the ways to cure them
does not come out of diagnostic and therapeutic manuals, but of
therapeutic dialogue and context?>>
Yes there are different traditions
which are linked to different practices which serve different social
functions. Traditionally diagnostically driven psychiatry
is designed to observe, diagnose, and then treat socially
divergent behaviour. Its aim is to restore the client or patient
to a socially adapted/ adaptive state in which his or her behaviour
fits within normal parameters. It is a corrective practice and can
be and has been on occasion coercive, but it can be and often is
simply normalizing, helping the client to reintegrate into
the social order and maintaining the necessary emotional stability
to function in relation to life’s tasks.
The more humanistic type of practice tends to aim in the opposite
direction, namely to help the client to stand back from convention
and to choose freely how he or she wants to actualize their
potential which may currently be hemmed in by unsuccessful attempts
at trying to fit into a conventional social framework. It may help
people to break free from unproductive relationships with significant
others or to liberate their creativity from humdrum and unfulfilling
jobs.
In practice, most good, and most integrative psychotherapist would
see a positive value in both these endeavours; to help someone
to have the social skills and emotional stability to play
their part as a citizen on the one hand, and to have enough resources
to make responsible and rewarding decisions on the other: human
beings need both, the capacity for forming and maintaining meaningful
relationships within the social and cultural framework of their
society and to find novel and creative forms of self expression
in the face of the challenges of ( post) modernity so that they
can carry out tasks which draw on both these capabilities.
Tullio asks:
<<In that case, shall we surrender to the irreducible
diversity of the two approaches, acknowledging that treating a patient
is incomparable with caring for a subject, or shall we understand
them as the two terms of a polarity, inside which every therapist
can conveniently locate himself or herself according to temperament
and preferences? >>
To an extent, as Paul and especially John,
have already observed, it is the client’s need which should determine
what therapeutic tasks need to be undertaken, and the
nature of the task will to a large measure determine the method or
approach used by the therapist at a particular point in the
evolution of the treatment. To an extent most therapists will be more
interested in or more skilled at a particular way of working
– more or less scientifically or more or less artistically. If the
therapist is self aware and responsible, such preferences will be
reflected in the kind of client groups a therapist chooses
to work with, which clients he or she refers on to a colleague, more
skilled in the empirically validated treatment recommended by any
national or international guidelines or protocols insofar as these
exist, are relevant or trustworthy. Integrative therapists may
be more versatile and able to function competently over a wider range
of treatment modalities and approaches than so called ‘pure
form therapists’, but this is a matter for scientific research to
decide, where therapist orientation is matched with client
outcome…
Tullio Carere, 27 January 2006
Dear Allan,
I am very happy that you make the points below:
<<I
agree that the object of psychotherapy research should be, as you
put it, “real therapy.” I gather, though (based on past listserv posts),
that you do not consider time-limited, protocol-guided therapy provided
in the context of a research study to fit that description. If I’m
correct in this understanding (and I apologize in advance if I have
misconstrued you), then this is perplexingly dismissive of the powerful
effects such therapies have been repeatedly demonstrated to have (as
well as of the “reality” of the therapeutic encounters I have experienced
in doing such therapies). It would also deprive us of excellent sources
of the data that I think interests both of us the most: live, meaningful
interactions between therapist and client.>>
To begin with, for the First Law of
DAP (Discussions among Psychotherapists), your belief in "the
powerful effects such therapies have been repeatedly demonstrated
to have" can be matched against the belief of others that the
effect of time-limited, protocol-guided therapies is almost irrelevant.
Consider, for instance, the results of Luborsky et al's 2002 mega-analysis
(meta-meta-analysis). Comparing active treatments, these authors found
a non significant effect size of .20 based on 17 meta-analyses, which
further shrank to .12 when corrected for researcher allegiance (see
also Messer 2001, Messer & Wampold 2002). Secondly, most efficacy
studies are based on a set of assumptions (namely, that psychological
symptoms are highly malleable, discrete, and relatively independent
of long-standing personality processes, that the primary focus of
treatment can be readily identified, that the elements of efficacious
treatment are dissociable and additive, that these techniques can
be implemented in a relatively brief span as prescribed in a manual),
assumptions that are not theory-neutral - if theory-neutrality ever
exists - but theory-specific of the behaviorism of the 1960s and 1970s.
Most of these assumptions are empirically testable, and many of them
have either never been adequately tested or have been empirically
falsified to one degree or another (Westen et al. 2004). You cannot
expect that a process-oriented therapist takes such studies in great
consideration.
Real therapy, to me, is what really happens in the relationship
between a patient and a therapist, not what the therapist believes
to happen as a consequence of his/her allegiance to a theory or a
protocol. But you are well aware of the difference:
<<Relatedly, I am also
perplexed by your suggestion of an equivalence between recordings
of therapy sessions, and post-session questionnaires. From
an empirical perspective, research on training of therapists in motivational
interviewing (the area with which I am most familiar) has shown that
the gap between what therapists think they are doing, and what recordings
show them to have been doing, is rather substantial (especially with
regard to expressed empathy). From a psychoanalytic perspective, this
should hardly be surprising: no matter how well-analyzed, therapists
have their defenses, and their own assessment of what has happened
and what they have done in a session should reliably be expected to
be distorted in various ways. For access to the rich intersubjectivity
of therapeutic process, it seems to me that there can be no substitute
for recording of sessions.>>
Does audio- or video- recording
permit us to understand what really happens in a therapy? Yes and
no, in my view - more no than yes. Too often have I seen videotapes
of therapists proudly showing them in the conviction that everybody
should see what they see - namely, the efficacy of their method
- whereas what I usually see is different to totally
different from what they see (not truer, just different). Tapes
don't record meanings, just behaviors whose meaning has to be interpreted
- and of course the meanings change according to the theory of the
interpreter. If you let go of the idea that a tape as such shows the
reality of a session, and accept that all you have is a material that
must be interpreted according to a theory that will be extolled by
some and rejected by others, your enthusiasm for such material could
rather fall off, especially if you consider that its processing is
extremely time-consuming.
In this state of affairs, you might consider the convenience of post
session questionnaires vs. recordings. For instance, the questionnaire
that we have devised in our small research group asks the patients
to rate on a 7-point scale the session outcome and 15 items describing
typical session experiences, like "I felt understood", or
"I have seen alternatives to my usual behavior" on two columns
(respectively, "This is what happened in the session", "This
is what I expected in the session"). The questionnaire does not
yields numbers to sum to other numbers to make statistics (a game
you can play, yet of poor relevance), because the ratings are very
context-dependent (a short discussion of the questionnaire at the
beginning of the next session is mandatory - it takes very little
time and generally is very useful). It is a simple and efficacious
tool to monitor and document the process, in the perspective of George's
Local clinical scientist (to be dialectically balanced with
the Local clinical artist). Much more practical and economical
than any recording, as far as I know. And, last but not least, it
heals the rift between practice and research, in the spirit of Freud's
Junktim.
Tyler Carpenter, 28 January 2006
For me I suspect that I am less
interested clinically in what divides psychotherapists. People make
distinctions by nature and may argue over their respective validity.
I find I'm more interested in integrating what I know of what
is known, in the patient and what they present for help with. In
this respect I find my self drawing on a lot about humans that present
itself in the context and conditions I am faced with. Because
my patients are currently typically seriously disturbed sex
offenders, this requires an integration of medicine-criminology-religion-developmental
psychopathology-culture. I see no distinctions between medicine-meaning-treatment-science,
except for the purposes of discussion with others or articulating
to myself what seems to be intuitively true and clinically effective,
or requires more investigation and thought together with the
patient and the context of treaters and security. To me to be therapeutic
is simply to say I got the mix right this time with this person. I
don't think that I'm idiosyncratic in this approach, for by the canons
of our respective professions and the nature of who we work
with, I suspect we make the distinctions which our patients
present us with for treatment in the settings we choose to work.
Or said another way, I think any well trained clinician who
undertakes to treat psychotic and character disordered criminals
in a correctional context in which the realities of getting a favourable
result (and preventing tragic and fatal ones) dictates that we take
meaning, context, level of systems, empirical knowledge, and medicine
seriously or not work successfully with those folks. Deviations
from such an "integration" seem to me to be more about
experience. In this light physics, chemistry, brain science,
sociology, anthropology, religion, psychology, etc. all have
their place and can be articulated in those meaningful moments and
periods when we and our patients can breathe "aha" as the
elements come together in the therapeutic ebb and flow. When
we work this way, severity becomes less severe and more treatable.
More like a difficult problem in the process of becoming a less
difficult one. If one perseverates and is rigid in ones thinking,
the question of the extent to which this stuckness is state
or trait, reflective of damage-development-context (or most
likely an admixture) drives the moment and the therapeutic response.
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. It's a little
like hardening the categories, when in fact that is the problem
to be understood and developed and processed in the moment. Why make
such a moment projective identification-cognitive distortion-perseveration,
when the solution is to standback and address the issue in one
of the numerous ways the patient, environment and tools might
address?! As to our relationship to doctors, that division
seems to be less distinct to me as the practice seems more consumer
driven and multi-disciplinary. To me some behavior and cognitive
therapy seems more like some types of medicine, but when I reflect
further or consult another practitioner or reflect on all that
is happening in my consult with my doctor, it seems that he
is drawing on a wider understanding of therapeutics where there is
much overlap in what he and I think that the problem is.
Zuckoff Allan, 29 January 2006
Dear Tullio,
It seems to me that, if “integration” means anything
when it comes to the methodology of psychotherapy research, it must
involve finding some common ground between “process-oriented” and
”outcomes-oriented” perspectives. While I am far from an uncritical
proponent of controlled psychotherapy outcomes research, and I believe
that questions about what the cumulative evidence shows thus
far are of great importance, your dismissal of this entire body of
research as “almost irrelevant” does not, I think, bode well for the
project of integration.
But let us stay, as you prefer, within the realm
of process research. You write:
<<Real therapy, to me, is what really happens
in the relationship between a patient and a therapist, not what the
therapist believes to happen as a consequence of his/her allegiance
to a theory or a protocol.>>
Here we are in complete agreement. Which makes the
critical question: how can we best research, and thus understand,
“what really happens in the relationship between a patient and a therapist”?
Your claim is that recordings of sessions are less valuable for this
purpose than I believe, due to the inevitable conflict of interpretations.
<<Tapes don't record meanings, just behaviors
whose meaning has to be interpreted - and of course the meanings change
according to the theory of the interpreter. If you let go of the idea
that a tape as such shows the reality of a session, and accept that
all you have is a material that must be interpreted according to a
theory that will be extolled by some and rejected by others, your
enthusiasm for such material could rather fall off…>>
This, I would argue, is not only wrong, but highly
ironic and (if it were true) ultimately destructive of any meaningful
research process. The position you articulate would leave us all trapped
in the hermeneutic circle—and thus forced in every case to insist
that any one construal of meaning is “not truer, just different” from
another. The irony comes from the fact that, by claiming that “behaviors”
have no inherent meaning, you are echoing a key (and mistaken) element
of the behaviorist position you otherwise reject. The destructiveness
derives from the fact that, like all post-structural positions, yours
fetches up in relativism and the death of truth.
Fortunately, one need not be a positivist to escape
this trap. Merleau-Ponty showed us how: phenomena (including behavior)
are both autochthonously organized (and thus inherently meaningful)
and intrinsically ambiguous (and thus open to multiple interpretations).
Varying perspectives may be more or less accurate—but some are truer
than others, and it is possible (and, if research is to be something
other than an endless circle, necessary) to adjudicate between them.
Thus, the problem of recordings does not lie in either
their multivocity or their capturing of only a part of the “reality”
of a session—but rather, in finding (one or more) methods that can
allow them to speak their truth (which is, of course, not “the whole
truth” but one part thereof). The method I have used begins with the
phenomenological reduction—impossible to complete, yet vital to undertake.
I have no doubt that other methods could be viable, as well.
I believe that the approach I am pointing towards
speaks to your own concern about interpretations of therapeutic process
being contaminated by the theoretical (and other) biases of those
who offer them as demonstrations of their therapy’s power. At the
same time, it shares the one virtue of controlled outcomes research
that I most admire: it allows for the possibility of falsification
of claims of efficacy through public (i.e., intersubjective) evaluation,
which is as close as we can come to true objectivity in this realm.
Post-session questionnaires, while of some interest, cannot come close
either to revealing the richness of therapeutic process, or to putting
one’s claims for the power of one’s form of therapy to the test.
Tullio Carere, 29 January 2006
Dear Allan, you write:
<<It seems to me that, if “integration” means
anything when it comes to the methodology of psychotherapy research,
it must involve finding some common ground between “process-oriented”
and ”outcomes-oriented” perspectives. While I am far from an uncritical
proponent of controlled psychotherapy outcomes research, and I believe
that questions about what the cumulative evidence shows thus far are
of great importance, your dismissal of this entire body of research
as “almost irrelevant” does not, I think, bode well for the project
of integration.>>
I strongly endorse a dialectic between "process-oriented"
and "procedure-oriented" perspectives (though I don't share
your enthusiasm for most efficacy studies so far). I do not dismiss
an "entire body of research as 'almost irrelevant'", but
others do. Some are enthusiastic of that sort of research, others
dismiss it (both on the base of robust empirical data: First Law of
DaP). Empirical research is necessary, and just because it is necessary
it must be criticized (as Westen does) for the way it has been done
so far, with so many unjustified and unwarranted assumptions and biases.
Above all, I agree with Westen that empirical research should return
to real therapy as a natural laboratory in the first place, in order
to draw from the observation of real processes the hypotheses to put
to test (as opposite to the "Popperian" trend in empirical
research, which only emphasizes hypotheses testing), with a much more
balanced mix of observation and experiment. I personally believe that
empirical research in psychotherapy should be much more of the correlational,
and much less of the experimental type.
<<… the critical question: how can
we best research, and thus understand, “what really happens in the
relationship between a patient and a therapist”? Your claim is that
recordings of sessions are less valuable for this purpose than I believe,
due to the inevitable conflict of interpretations… This, I would argue,
is not only wrong, but highly ironic and (if it were true) ultimately
destructive of any meaningful research process. The position you articulate
would leave us all trapped in the hermeneutic circle—and thus forced
in every case to insist that any one construal of meaning is “not
truer, just different” from another. The irony comes from the fact
that, by claiming that “behaviors” have no inherent meaning, you are
echoing a key (and mistaken) element of the behaviorist position you
otherwise reject. The destructiveness derives from the fact that,
like all post-structural positions, yours fetches up in relativism
and the death of truth. Fortunately, one need not
be a positivist to escape this trap. Merleau-Ponty showed us how:
phenomena (including behavior) are both autochthonously organized
(and thus inherently meaningful) and intrinsically ambiguous (and
thus open to multiple interpretations). Varying perspectives may be
more or less accurate—but some are truer than others, and it is possible
(and, if research is to be something other than an endless circle,
necessary) to adjudicate between them. Thus, the
problem of recordings does not lie in either their multivocity or
their capturing of only a part of the “reality” of a session—but rather,
in finding (one or more) methods that can allow them to speak their
truth (which is, of course, not “the whole truth” but one part thereof).
The method I have used begins with the phenomenological reduction—impossible
to complete, yet vital to undertake. I have no doubt that other methods
could be viable, as well. >>
I surely am an adversary of scientism, i.e.
the belief that science is the ultimate key to crack open the mysteries
of life and existence. All scientific enterprise is based on some
indemonstrable belief or subjective choice (even mathematic, as Goedel
saw and showed). The death of truth is rather a consequence of the
hubris that claims that truth can be objectively known. All objective
knowledge is the result of some epistemological choices of the subject
(which the subject is usually not aware of). This awareness, though,
does not make of me a post-modernist relativist. On one hand, this
makes me try to recoup the dialectic of the subject and the object
wherever it gets lost (in positive sciences it usually does) - which
means that I always try to uncover the hidden presuppositions, choices
and beliefs behind any "objective" knowledge. On the other,
I don't believe that we are fatally trapped inside our subjective
points of view - or hopelessly conditioned by the conditions of our
lives. To the contrary, the liberation of the subject from whatever
traps or conditions his or her existence is to me the very goal of
any psychotherapeutic effort, from the shamans on. Bion's formula
"freedom from memory and desire" epitomizes well this basic
thrust, and the phenomenological reduction is an important aspect
of this freedom - at least its first step. I am glad to read
that your method "begins" with it. You must be aware, though,
that it is not enough to begin with it. To become aware of all one's
presuppositions, judgments and expectations, and to suspend them continuously,
is a very hard discipline, and I would not say that it is the bread
and butter of most of those who devote themselves to empirical research
- who therefore quite often remain stuck with their unsuspended
and uncriticized presuppositions. But maybe we could agree on this
point: science has a good chance of not corrupting into scientism
to the extent that the scientist practices a good enough epoché from
the start to the end of his or her work.
<<I believe that the approach I am pointing
towards speaks to your own concern about interpretations of therapeutic
process being contaminated by the theoretical (and other) biases of
those who offer them as demonstrations of their therapy’s power. At
the same time, it shares the one virtue of controlled outcomes research
that I most admire: it allows for the possibility of falsification
of claims of efficacy through public (i.e., intersubjective) evaluation,
which is as close as we can come to true objectivity in this realm.
Post-session questionnaires, while of some interest, cannot come close
either to revealing the richness of therapeutic process, or to putting
one’s claims for the power of one’s form of therapy to the test.>>
I don't admire most controlled outcome research for
the too many unwarranted assumptions on which it is based. But I do
believe that empirical (above all correlational) research can be done
in a much more critical and useful way. For instance I admire the
work of Stern's group (the Boston Change Process Study Group) on audiotaped
transcripts, in which they illustrate how much " sloppiness"
(fuzzy intentionalizing, unpredictability, improvisation, variation,
and redundancy) generates unpredictable and potentially creative elements
that contribute to psychotherapeutic change. I think the Dodo bird
would appreciate that his (her?) verdict receives one more empirical
support. Post-session questionnaires might be less useful for such
purposes, but I value them a lot as precious tools for monitoring
and documenting the process at disposal of the local scientist. There
is a great deal of unpredictability in the psychotherapeutic process,
and I believe it is an "inherent property of intersubjective
systems" (as the BCPSG puts it) in spite of those who believe
in manualized treatments. If this is the case, let the therapy go
its own way, but let us produce objective material (questionnaires
are literally objects that can be intersubjectively examined, like
audiotaped transcripts) to document the process.
Continue
to read the listserv discussion during February
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