Psychotherapy Integration

Hilde Rapp, 1 March 2006

 Allan wrote:

<<I understand theories as well-organized explanatory frameworks, which can be applied to a range of phenomena and which are capable of generating either hypotheses that can be tested empirically or truth-claims that can be evaluated rationally>>.

I agree entirely, a theory needs to be able to organize observations, generate lawful or at least orderly relations between them, predict  what novel observations would be expected to fall under the scope of the theory, be testable empirically, or capable of rational justification via logical argument. 

It was precisely this understanding of the role and nature of theory which led to the evolution of the assimilative(- accommodative) integration ( pre?)paradigm.  

T he debate was/is (see Messer et al 2000/2001? the JPI assimilative integration issue) about what transforms or re-descriptions of a borrowed technique, or what  reformulations  of a theoretical term,  might be  possible so as to allow it to be integrated into  the  theory which informs our practice  without distorting  either theory or praxis in any serious way…

 There are clear exclusion criteria   at stake which have been variously articulated in our literature  and which   constrain the principled ( here Tullio’s term is very apt) transposition and inclusion of new thinking and  ways of working, whatever their origin,  into an espoused theory  if this  is to retain any meaningful  family resemblance to the  theory in use by a practitioner.

  Hilde Rapp, 1 March 2006

 Allan wrote:

<< Existential phenomenology (specifically, that of Merleau-Ponty) starts from the premise that “internal” and “external” are, like all such dualisms (e.g., “mind” and “body,” the “immanent” and the “transcendent,” the “ideal” and the “real”) derivative constructs of an inherently unitary world of phenomena of which human beings are constituents (in the Gestalt sense of mutually constitutive parts of a whole, inseparable from each other without losing their essence). This is a remarkably hard thought to think (I’ve been working on it, on and off, for 25 years or so), but possibly the thought that leads to the aufhebung of many destructive dichotomies. Science? Probably not. Reductive or Religious? Definitely not.>>

 To think of our being in the word and of the world in which we are and do as “mutually constitutive parts of a whole, inseparable from each other without losing their essence” is indeed “a remarkably hard thought to think”.  This also exercised Freud more than somewhat – and indeed, Bion.  I have (reluctantly) come to the conclusion that we can, in certain meditative states which include the psychoanalytic art of ‘free association’, and ‘mindfulness’  in  cognitive behaviour therapy , experience wholeness and unity.

 I do, however, not know how to convey this experience of unity  in  the form of narrative discourse, nor, in the strict sense of the word, do I know how to think  such a thought- my mind seems to be too small for that. I therefore contend myself ( reluctantly)  with recognizing and respecting  that different disciplines and their different epistemic foundations and methods of  enquiry have  come about in order to addressed this task in piecemeal fashion so as to make thoughts smaller and thus  thinkable in a coherent way .

 The ground map for my four quadrant meta- framework therefore sets out four different starting points for a collaborative and integrative endeavour at understanding ourselves and our world in ways useful for the practice of psychotherapy.  I suggest that we draw on the  wealth of historic traditions which define different universes of discourse,  bodies of knowledge, wisdom, experience, practices, and peer derived conventions  that  give shape and content  to each of these ( notionally) four families of logic of inquiry into :

 1. subjective experience ( phenomenological)

 2. collective meaning making ( hermeneutic)

 3. human development (evolutionary/ human sciences)

 4. understanding society and environment (complexity/ living systems approaches ).

Each  epistemological enterprise addresses a particular  area of enquiry particularly well and looses its force and scope  in relation to another.

 As integrative therapists we need to be clear an honest about which of the following  two  kinds of endeavours we are engaged in. the making  meaning of our experience  or searching  for knowledge and explanations. We  need  both to practice. We may be temperamentally inclined to wards one or the other. We pick clients who benefit more form our intuitive wisdom and skill, or clients who need more direction and systematic support. All the same  our art, craft and science relies on  both scientific  research and emotional intelligence…

 1. Sharing Experience and Making Meaning  for the Sake of the Client’s Wellbeing ( largely  informed by 1 phenomenological, and 2 hermeneutic endeavours: reflection, contemplation, intuitive understanding and interpretation)

   Seeking  a means for pointing to an experience so that we can share something about it that makes us more compassionate, more sensitive and observant, more humble and yet more daring when we grapple with  dark forces,  lies  at the centre of our praxis.  We are working with our capacity for violence, our capacity for deception, but also our passion for what is beautiful and erotic and our hopes and fears and our search for truth.

 This is the crux of psychotherapy – something happens in the consulting room between the client and the therapist which is actually ineffable because we cannot unpick it from the context of the living and lived experience without it loosing much of its meaning and its significance for change.  

  We may  call it transference, projective identification and so on if we are analysts, empathy, mirroring if we are person centred, modeling if we are behaviour therapists,  parallel process if we come from Gestalt, shaping if we are learning based,  resonance , following and leading in  NLP, experiencing, if we are experiential , therapist and client factors in the common factors approach, and the relationship,  if we  are cautious  about avoiding  what may sound like jargon and so on.

 We work with these phenomena and we know that they are essential to therapeutic outcomes.

 Although he abandoned this position later, Wittgenstein once said something like “there are things that can be said, and things that can only be shown- and about that of which we cannot speak we should remain silent…” but then he was a philosopher. We as therapists ( must?) dare to speak ( clumsily) about those ineffable things because we are practitioners and not logicians…We need to achieve what Jerry Bruner calls joint deixis, that is  a line of gaze that points us to the therapeutic experience we want to share, collaboratively seek to understand so that we may  find ways of working more effectively for the sake of the client’s wellbeing.

 The best we can do is to circumscribe  what it is about  the whole that we can experience but not speak about

 Adorno recommended an essayistic circumlocution  of the ungraspable object of our enquiry. Like the poet , we might  encircle what we are after enough to narrow down where we should look- with inner and outer eyes: out quarry is in that symbolic thicket over there!  Merleau Ponty or Husserl  language this  enterprise differently, but I think they are after the same thing. Long live epoche,  the inevitable  adhesions of preconceptions not withstanding,  and may the cloud of unknowing  shield us all from hybris…

  Perhaps we need to bear our relative smallness and ignorance and  accept  that these ineffable experiences at the  heart of the therapeutic encounter  cannot be theorized   in the sense of making  the sort of “ truth-statements” that  should be foundational to a “proper” scientific theory.   Perhaps they can only be “theorized” in the original Greek sense of the word which  refers to a way of seeing linked to  an exercise in aesthetics and ethics rather than  to  an effort after explanation in a natural science sense.  Here we  are after an activity, a verb, to find ways of seeing and interpreting  reasons and justifications,  rather than  that construct a systematic edifice which accommodates the relations between causes and effects?

  We can speak about things, but not of them, but we can show phenomena ( appearances)…

 2. Picking out and languaging an aspect of our experience to generate knowledge( largely informed by  3. evolutionary/human sciences and 4. living systems approaches: observation, description, explanation, treatment and prevention)

  We endeavour to generate knowledge by  become more competent at   picking  out  an aspect of that whole   and to   language it  in such a way  that we   come  to know  something new and specific about  this experience which does not depend  for its understandability on the  unmediated access of  an embodied experience  or the context in which it appears .  The experience is mediated, abstracted and  symbolically expressed  (Hegel’s Vermitteltheit). Although we loose a lot in the transmission, what we can say still makes enough sense to be useful and informative to others who work in the same area- and if we are lucky it makes sense to people at large, at which point it may  approximate to knowledge.

 Observation and Description:  We seek to describe in relatively unambiguous language any observable effects of these clinical phenomena such as  resonance, f critical moments, or change events.

 We  want to specifically  exclude  what we may know through our imaginative participation in the privileged experience in the actual therapy situation.  We want to objectify and decontextualise that which we wish to study. Such objectivising approaches are  nonetheless not  ‘theory free’.

There are no ‘data’ ( givens) , everything is interpreted, but the theory  in this context is  a sort of contamination.

 We aspire to    translate  natural language terms with all their semantic fuzziness into formal language terms – we deliberately  set out to create jargon  that is stripped of ambiguity because the word is not normally used outside the scientific arena for which it has been formulated and so does not acquire  contextualised meanings.

We admit that  we cannot wholly  succeeded- we are self reflective- but we continue to try to make something like DSM3R or DSM4 or ICD 10 as clean and descriptive as we can./ We do our best to  categorise and classify the observable effects/ symptoms of ineffable psychic  and relational processes in a descriptive way. We aim to set signposts that reliably  point us to roughly the same place in the forest of symbols. ,

 Observation and Explanation: We want to be able to  identify the object of our inquiry as accurately as possible.  We want to be able   to compare one client with another on the basis of clear selection criteria . We want to map  comparable  patterns in client behaviour. We want to examine  their relationship to the clients life conditions. We want to see whether certain effects are reliably associated with certain causes. What makes people vulnerable or ill? . What is the natural  history  of a disorder?

 Treatment and Prevention We want to know what the therapist and client  do together to see who works well with whom and who does not,  and what works and what does not, and what sort of therapist behaviours  work with what sort of client difficulties.

 We endeavour  to specify  therapeutic procedures  in the form of treatment  manuals so we can test certain hypotheses about  what facilitates or hinders the occurrence of experiential and relational  phenomena  which we believe to be associated with change.  We need to be able  select clients  who are well described by a particular label in a common classificatory system. We need to  ascertain whether therapist A and therapist Z  are  both performing the action specified by their espoused  theory as effective and we need to be sure that  this is significantly different from what therapist B and O are doing who espouse different theory. We want to know which method is more effective.

 We also want to study   what factors can  to prevent distress or disease, so that we can  help to  ameliorate it better and faster.

  Processes  We are curious to identify behavioural markers for psychic events and processes  which we cannot directly access, but which we know from our own experience as practitioners, take place.  There- that look- that inclination of the head- that silence- that breath- seems to correlate with a critical event- does it?  The use of  imagery, metaphor, laughter  precedes a  shift – is this a pattern. ?   

 Here comes the rub –( or is it an invitation to integration and learning ?) :

  We can  only meaningfully  pick out an aspect of therapeutic experience for this kind of objectivising scrutiny because, ( provided we are practicing therapists),  we already have direct – presentational- ( see also Shannon’s excellent arguments for this )  experience of  the whole from which we are now picking out  a part for our special attention.

  We are in the same business. Although our experiences are not exactly  the same, they are often similar enough for us to be able to recognize our own experience in someone else’s account, description or analysis of what occurred in a session or treatment.

 This is how we learn from other people’s experience and how we come to enrich our own.  We have the Aha-experience of  yes ! this  is what happened in my session,  yes:  this is a useful interpretation of something I have been struggling to understand, oh good she also thinks that this is a good technique…

 This prior orientation allows us to understand  where a given  linguistically or symbolically mediated re-presentational   (and probably  logically  incomplete)  sentence or description is pointing. We may recognize our client in a particular DSM description and we may find that a clinical guideline  for  how to work with such a client illuminates  for us what to  do better tomorrow.

  The guideline may give us a road map  for   setting  up the facilitating conditions to give space to and bring about a particular therapeutic experience which replicates the kind of experience the clients who were part of the sample that was used to construct the guideline may have had that  may have helped them  to change.   

 The map is not the territory : description is no substitute for experience

 The writer of  a  cookbook   or a therapy manual doesn’t claim that it makes you an inspired or competent cook or therapist ,it doesn’t create an intimate atmosphere, it doesn’t equip you with the sense of smell that tells you that  something stinks, it doesn’t regulate your flame or prevents you from burning the meal. It just  describes, how you might  use certain ingredients to create a constituent  of the whole experience – the meal- not the encounter within which the meal plays a part, nor whom to invite. Nor does it forbid you to alter the recipe. It merely describes...

 Whether it helps our praxis to use a guideline or to copy another colleagues technique  is partly a function of whether we are a ‘good cook’, whether this is the right time, the right chemistry and whether we have the right ingredients for a therapeutic experience to arise  and whether we have to wit to recognize a change event  for what it is when it does occur.

  I have not really met anyone within  SEPI  who confuses the map ( symptom checklists of whatever kind – or the recipe, ie  descriptions of observable relationship events, or behavioural  markers of features of an  emotional landscape) with that territory where Virgil dares to walk with the leopard!

  I also  I think we do, on the whole,  know the difference between this leopard and a paper tiger quite well- thank you  to all within SEPI!

 Both the effort after meaning and the effort after knowledge are paths to understanding   within a  civilizing endeavour- to bring out the best in us as individuals by way of self realisation and self definition  on the one hand  and to socialize us to be fit for  building relationships  as global citizens through attunement,  self restraint and co-regulation in the service of joint action… on the other.  

 Experience without science is dumb ( speechless) and science without experience is dead (lifeless ).

 I apologise that I needed so many words to mutter  this. We can, as Allan wrote, only ever “ asymptotically” approximate to the truth.  

Tyler Carpenter, 1 March 2006

I agree with your general slant on things, Tullio. Sorry I can't join you  for a Chianti or cappuccino in the near future, but when I'm in the  neighborhood I'll bring a home brewed beer (I just finished making a Belgian Tripel and will bottle a Barley Wine April 1st).‑

More particularly:

Sometimes group process is muddled with paradigm clashes. I would add to the concept of a disciplined mind, the zen concept of no mind. Sometimes even disciplined minds run into subtle distinctions that are obstacles in the path to a larger understanding of the topic at hand. The late Chogyam Trungpa Rinpoche's concept of "spiritual materialism" is related to the idea that individuals, even bright ones, can fetishize  concepts (especially ideals) and then get caught up in the detritis  of certain distinctions and emotional reactions.
As a former academic - medical school research team member, I have a great appreciation for the role that disciplined study can bring to any orientation that one chooses, as long as the data and context are clearly understood. Here I suspect I think similarly to Tullio. ESTs can also simultaneously be great tools for the apprentice and journeyman and patient on an individual path of change, or if tweaked by the expert, an adjunct to systems interventions or psychotherapy broadly conceptualized. I would add to the concept of treatment as ethically based, that of evolutionary and adaptive biology. If the applied values didn't have survival value for the
individual and the group, there would be little or no purpose or effect in applying them. When you add biology-chemistry-neuroscience to the pot, things begin to bubble and savory smells emerge.

Hilde,

I would add,  that particularly when we begin to drop the need to define all in one framework, different levels of systems often provide their own vocabulary and framework that complements other levels. When each participant (or group) deals with the issue as they see it and it (their conceptualization) is perhaps tweaked a bit to function both for them and in doing so for the systems, then the whole may lumber on adaptively without the impediments that separate conflicting vantage points can often bring to what is essentially a unitary process, regardless of our attempts to name it and its constituent elements. What I am struck by again and again is the
lack of understanding different groups have of each other and how often just providing common ground, without exchanging worldviews, is all that is needed for good enough adaptations to become emergent.

Dear Paolo,

On ethics          I'm not sure that relying on ethics is anymore or less useful than relying on theories of therapy (especially given their partial correlation with one another). Ethics are often based on precisely what you suggest makes them unworkable as a foundation for treatment, namely the different schools of reasoning that govern the ways in which one may integrate the various common principles that one may invoke when addressing a common problem. The approach is both nomothetic and idiographic and this dual nature is built into the body of the discipline.

Tullio Carere, 2 March 2006

George Stricker 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.>>

George,

it is wise to prefer the inevitable. In my view we are all assimilative integrationists, inasmuch as we all start with a theoretical base that we form in the years of our training, and go on building on that base through our entire professional life. When we assimilate something, we have to change more or less our home theory to accommodate the new thing, as you point out. As a result, in the course of time the building grows into a mixture of the original theory unmodified (which already is an idiosyncratic collection/selection of the original inputs), the original theory modified to accommodate the assimilated foreign bodies, foreign bodies not really assimilated but hanging around in a more or less eclectic way. The bottom line is that we have hundreds of schools, thousands of subgroups, and virtually as many psychotherapeutic theories as there are psychotherapists in the room. The paradoxical outcome of assimilative integration is that the individual psychotherapists become more integrated, to the extent that they integrate into their original approach modes that originate elsewhere, while at the same time the psychotherapy field becomes more and more dis-integrated.

We are all very happy with our idiosyncratic assimilative integrations, as we also are more or less painfully aware of the resulting disintegration of the field, and struggle towards some form of integration -- this is why SEPI came to existence, I believe. I am not as optimistic as David about the feasibility of a theoretical integration between, say, two incompatible but reasonably coherent theories like psychopharmacology and psychoanalysis (if psychoanalysis were a coherent theory, which is not). But it should be clear that the very idea of integrating hundreds or thousands of incompatible and incommensurable (and incoherent) theories is absurd. This is why I say that the only possible integration of the field happens on the pragmatical ground, i.e. the common ground where we find a number of common factors, and where a communication among us, independent of our theories, is possible.

Sure enough, research has been done, and more research must be done on common factors. But I dare say that empirical research as it is commonly meant (on the blueprint of medical research) is not very fit for investigating common factors. For the simple reason that common factors are not "ingredients", or "procedures" which one can "manualize" (what can an empirical researcher do without manuals, or at least precise enough guidelines?). They are not behaviors of the therapist (observable, recordable) --  they are experiences of the patient. For instance, we know that every therapist, of whatever school, must respond properly to the basic need of secure base virtually present in all patients. But there is no way to know in advance what will be reassuring for a given patient in a given session. One will feel at ease in a rigid setting experienced as persecutory by another who will feel secure in a flexible setting. Experiences cannot be observed from the outside, yet they can be investigated not just in-session (which is obvious), but with post-session questionnaires, integrated with written notes by both patient and therapist. This material permits to monitor and document the process, and to correlate process and outcome. If the object of research is not behavior, but experience, the research should not be experimental, but documental.

We diverge among us inasmuch as we integrate in the assimilative mode, we converge in the common factors approach, which could also be properly called accommodative integration. We can observe common needs and common therapeutic factors, and facilitate their emergence, expression and development, to the extent that we know how to bracket out our theories and get tuned in the process that develops in its own right. Too much assimilative integration makes the therapist self centered and insensitive to the process, too much accommodative integration is detrimental to the therapist's coherence. "Ideally, one might expect to see a fairly even balance between assimilation and accommodation, with neither predominating to any great extent". Paul wrote this sentence with reference to individual treatment, but it also applies to the field as a whole.

Barry Wolfe, 2 March 2006

Hello All,
I would like to weigh in with a vote for working toward a unifying conception of psychotherapy, even though this may strike us now as an unrealisable goal.  There are two reasons for this: 1) there is a lot of theoretical redundancy in our various theories of psychotherapy and in the disorders they treat and 2) some theoretical propositions within each theory are just plain wrong.  For example, in my recent review of the various extant theories of anxiety disorder and their treatment (Wolfe, 2005)*, I found that psychodynamic, cognitive-behavioral, and humanistic/experiential theories all argue that we are ultimately attempting to bring about change in tacit internalized psychic structures regardless of the theoretically-based terms we give them (i.e. unconscious character traits,
cognitive schemata or tacit emotion schemes).  Secondly, psychodynamic theories need to "accommodate" the fact that exposure therapies can effect symptomatic improvement in virtually all of the anxiety disorders, while behavioral theories need to accommodate the fact that there are tacit
dimensions to anxiety disorders (even phobias) that are responsible for both the development and maintenance of these disorders.
These are just single examples of what I believe is a fairly wide-spread need for trimming theoretical redundancy and engaging in a significant amount of theoretical accommodation.

George Stricker, 3 March 2006

My response incorporates a response to an early post from Allan as well as yours Tullio. I agree that my approach is within the realm of normal science, to use Kuhn's term, and also that psychology (not just psychotherapy) is still pre-paradigmatic. My preference for normal science rather than Allan's Nietzschean solutions (theorizing with a hammer) is based on my pessimism about the approach that so many others are favoring. Physics, which is far in advance of us, and is paradigmatic, has been searching for a Grand Unified Theory in vain, at least to date, and that does not encourage me as to the prospects for psychotherapy achieving success at a GUT. In the meantime, we still have to serve our patients, and the best avenue, in my mind, is through assimilative efforts and a search for common factors, probably located in a region at a level lower than theoretical. By the way, Tullio, I wish we all were assimilative integrationists, but I think many people function as eclectics, free from theory, although I've never been enamored of that approach.

Zoltan Gross, 5 March 2006

How does one convince others that the earth rotates on its axis while traversing its orbit around the sun, when it is important for them to know the sun rises in the East and sets in the West?

I agree with George Stricker that both psychotherapy and research psychology are in a pre-paradigmatic stage of theoretical development.  However, with the introduction of information from neuroscience, I am more hopeful than he is about the prospects for the creation of theory of personality that is both researchable and clinically useful.  At present, theorizing about personality is an outside-in way of looking at it.  We observe the behavior and the reported experience of people with common sense cognition that is linearly and sensorially formatted.  This information is then passed through lens of Western cultural tradition and belief.  As a result we are greeted with descriptions of personality spoken in different "languages" (paradigms) using the same words but which have different meanings. There are no consensually agreed upon definitions about such words as personality, person, self, emotion, or cognition. Furthermore, none of these terms have theoretically elaborated relationships with one another.  In effect, I believe   we have been anthropomorphizing cerebral operations based on commonsense cultural biases.  I find it difficult to believe that "meaningful" assimilation can readily occur when this epistemological barrier exists. 
Early on in my practice I realized that common sense contributed more to my confusion than to psychotherapeutic growth.  When people returned their "repressed" to me I found that they were "returning" what I had asked them to return.  Nothing much happened with that exchange.  The operation of the Pleasure Principle was rarely seen except when it came to ice cream cones.  Plato's and Freud's hoped for sovereignty of reason over passion didn't exist.  Reason was always swept away when the storms of passion, anxiety, depression, or pain passed over the landscape of the individual's personality.  As I came to see how congruent the dualities of personality operations were to the doubly dual structure of the brain, I abandoned "common sense" as a guide to my work.  I found my self engaging in some of the wisdom of the Theater of the Absurd and the Sufi and Zen mystical traditions. The differences in information processing of the left (linear) and right (nonlinear) hemispheres and anterior ("executive" and emotional - nonsensory) and posterior (sensory) lobes helped me to better understand the relationship I was having with the people with whom I was working  Since personality operations are largely relational and are nonsensory it is extremely difficult to describe them in common sense formats.  Instead, applying Averill's idea about functional analysis to cerebral operations (an inside-out way of looking at personality) it is possible to create a theoretical paradigm that can accommodate the nonlinear (relational) and
nonsensory (selves and emotion) dynamics of personality that is both researchable and clinically useful.  We are now on the threshold of the creation of a new psychological paradigm.  The achievement of Freud's Scientific Project is now possible.  With it, we can escape the limitations of "folk" psychology upon which we currently rely.  It is not enough to know that the sun rises in the east and sets in the west.  This belief could lead us to believe that we are at the center of the universe.  We have a richer and less limiting understanding of where we are in it, when we know about the dynamics of our orbital relationship to the sun. The wish I have just outlined hasn't happened yet, but I believe that it can.

Allan Zuckoff, 6 March 2006

Tullio wrote:

<< For instance, we know that every therapist, of whatever school, must respond properly to the basic need of secure base virtually present in all patients. But there is no way to know in advance what will be reassuring for a given patient in a given session. One will feel at ease in a rigid setting experienced as persecutory by another who will feel secure in a flexible setting>>.

 Tullio,

Each of the three statements above is a) theory-specific, and b) empirically testable. Manuals are much less limiting (and limited) than you suggest, and it would not be that difficult to do a study in which one group gets therapy that is attuned to these polarities and adjusts accordingly, while the other gets a one-size-fits-all approach. And the results of the study would allow us to go from assertion to research-supported positions on these critical questions.

Hilde Rapp, 6 March 2006

Dear Allan, dear Tullio,

 Such research exists- especially within  Shapiro paradigm of altering the sequence  in which conversational- relationship focused interventions  and cognitive behavioural interventions are delivered –  Members of the Society for Psychotherapy Research in the UK can help pinpoint  where particular studies may be found…

Allan Zuckoff, 6 March 2006

Hilde wrote:

<<The ground map for my four quadrant meta-framework therefore sets out four different starting points for a collaborative and integrative endeavour at understanding ourselves and our world in ways useful for the practice of psychotherapy…>>

 Dear Hilde,

Your post was challenging and complex, and I found much to admire in your views as well as in the humanity that spoke so clearly through them. I must, however, have another go at challenging the epistemological assumptions of your meta-framework.

 Much of your post centered around the dichotomy of the “subjective” and the “objective,” understood through a traditional philosophy of science. In this model, there is a “subjective” realm of immediate experience that cannot be directly accessed by others, and an “objective” realm of mediated knowledge that can. Of course, these categories also correspond to the traditional ideas of “mind” (that which is private) and “body” (that which is public).

 I would like to propose that this model, universally accepted since Descartes, is precisely what has led to all kinds of conceptual trouble and needs to be jettisoned. That is to say: because we are “incarnate consciousness” or “animated bodies” (the two terms mean exactly the same thing), mind and body, subjective and objective, can never by separated without doing violence to reality. (And the trouble has not only been conceptual; once we dichotomize mind and body, we prepare the way for the demonization of the erotic body that has plagued the West for the past couple of millennia). Our experience is always mediated and accessible to others: not, as the poststructuralists and anglo-analytic philosophers after the linguistic turn would have it, because we are born into and formed by language (though we are, in part), but because we are flesh, and we recognize ourselves in the flesh of others (Merleau-Ponty called this the chiasm, or intertwining), and the meanings we perceive are not merely “imposed” by us (because, then, how would we ever know whether we are imposing the correct meanings?), but inherent in reality. What is, is autochthonously organized; we are part of what is; and we perceive that organization because it is there, and because our perception is a constituent of its coming-to-be.

 So, one might reasonably wonder, what are the implications of all this wooly philosophizing for psychological and psychotherapy research? Well, one major implication is: we need to stop using the term “phenomenological” as a synonym for “subjective.” Empirical-phenomenological research is not merely the elaborate description of subjective experience. It is a (human) scientific method for accessing the real essences of things, the meanings that inhere in phenomena (which is all there is). It provides analyses of descriptive data that allows us to “come to know something new and specific about this experience which does not depend for its understandability on the unmediated access of an embodied experiencer or the context in which it appears.” It does not, of course, provide us with “objective” knowledge—but only because the very idea of “objectivity” would require that we could view the world from a God’s-eye view, and because, once we “decontextualize that which we wish to study” it is no longer what we wish to study. (What is, is organized as figure/ground, theme/horizon; the theme does not exist without the horizon, nor the “object” outside its context.) It does, however, provide us with knowledge that can be replicated (or falsified), and allows us to test hypotheses and make truth-statements.

It does not, it is true, allow us to speak of “cause” and “effect”—and, as problematic as those constructs are within a phenomenological framework (and within a quantum physics framework, for that matter), we clearly do wish to be able to make such statements—we need to conceptualize the world in these terms (at least for now). So research along the lines of our traditional understanding of science is needed, as well. RCT’s tell us part of what we want to know—does doing therapy one way bring better outcomes than doing therapy another way?—and, pace Tullio, it is not hard to separate studies done from a standpoint of openness to any outcome from studies (like those of the Vatican “scientists” Tullio invokes) whose outcomes are predetermined. (All “empirical” research is not created equal.) It’s just important, I think, that we recognize that this is not the only path to genuine knowledge—and that the knowledge we gain via methodologically sound empirical-phenomenological analyses may ultimately tell us at least as much about what we most want to know.

Tyler Carpenter, 6 March 2006

I suspect that the phenomenon that Tullio is referring to is more subtle than the research solution you are proposing, Allan. Evidence of such security is highly idiographic and relative to not only the specific relationship, but such factors as timing, nature of issues being addressed, etc. Security itself is dimensional, as well as being both state and trait-like. Are we talking Ronnie Laing's "ontological insecurity" - his philosophical labeling of the phenomenological state of biomedically based psychoses, the individual's willingness to risk insecurity because of their faith in the security of the relationship, etc.?!  What constitutes a multi-dimensional dependent measurement which both reflects the levels of system in the individual, but also allows for comparisons across and within
groups? I'm not being a nihilist here, and I certainly appreciate good research, but we don't need more studies looking at changes in verbal behavior linked to theory and interventions. I remember years ago reading Walter Mischel's (I think) conclusion that one of the flaws of analytic research was that in order to examine concepts with real construct validity, one was forced to stay close to the surface so to speak.
Although I suspect that high-speed computers and chaotic models used for weather and economic forecasting would be one entry into more sophisticated research, we would not be mired in the lose-lose discussion about ESTs vs. dynamic models if we had something better and transtheoretical to examine. This stuff is hard to think and talk about, let alone study reliably and validly.

Tyler Carpenter, 6 March 2006

I'm not sure that many would argue your points regarding the limitations of an epistemology derived from those terms as you have done, Allan. The issue is not whether reality is as complex as you describe, but how do we chose constructs that by their very definition violate the integrity of the whole, but allow for a more dynamic examination of their operation in the context of therapeutic relationships? Said a different way, I don't think that one needs to toss out the terms objective and subjective, so much as to study their relationship within the epistemology you suggest. Whatever terms you use to describe the component parts, the success of the design is going to rise or fall on your ability to establish meaningful construct validity and then demonstrate replicable results between the manipulated variables. Part of the problem with the EST stuff I've read is that it is such a weak approximation of the reality of the therapeutic relationship (let alone complex formulations of real psychopathology) that it is hard for results to establish much more than we already know or to say something more about a limited number of dimensions in a multi-dimensional phenomenon.

Hilde Rapp, 6 March 2006

Dear Allan,

Thank you again  for taking the trouble to point out  that,  as expressed so far in this discussion, my meta- model  has been presented in a way that leaves too much room for misunderstanding.

 Yes, of course there is no such thing as a monadic subjective mind- we understand ourselves and we think about ourselves through language- I am with Benjamin Lee Whorff and Lev Vigotsky on this, and significantly also with Bakhtin: our imagination is inappellably dialogic.

 And of course there is no such thing as an objective, or natural,  science in which our observations are free from subjective  as well as collective distortions  by way of observer effects, perceptual set effects and context effects, let alone expectancy, interpretation, ‘ideological’ bias  etc  ( the first thing I learnt  in my course on measurement, decision and control, looking at the  psychology of perception and cognition,  when measuring reaction times to  stimuli of a certain luminance!). 

 My meta- framework  is purely heuristic- it does not  aim to set out an epistemic position: it  merely takes account of the fact that there are bodies of ‘knowledge’ ‘out there’ which  subscribe to certain epistemic assumptions, such as  ‘direct access to the contents of our minds’, ‘unmediated’ experience ( for instance within  Buddhist inspired mindfulness  based cognitive therapies – we can’t actually prove that our sense of having a direct experience of unity is not an illusion related to a particular biochemical- bio-physical brain state…), or a position  which  prefers to remain entirely silent about anything we cannot directly observe and measure as in  radical behaviourism  whether informed by  Occam’s razor or  modesty, making no  positive assertion that what we can’t see doesn’t exist…  . 

My meta-framework is  an ordering device, it aims to map what is out there for a particular purpose relevant to your current therapeutic task: if you want to find reports, studies, information, theories  etc  relevant to  certain aspects of your work, -  I invite you to look through the lens of this or that quadrant and you may find relevant material.  

Each person who chooses to use this  framework is invited to look at their client work from all four aspects, even if , ostensibly, the ‘problem’ which necessitates  some research or enquiry seems to be clearly located in one quadrant: the clients social skills are appalling, say, and we are looking at this in relation to developmental ‘deficits’ ie from a Q3   biological basis of behaviour and social developmental patterns of attachment, affect regulation, failures in ‘mentalisation’ and  schema based relationship formation perspective …   

 It may help to also look, even if only in passing, at what beliefs, attitudes, phantasies and existential torments might  inhabit the client’s mind- and indeed our own (Q1), and to do so  with an eye on philosophies past and present, be that the Buddha or Descartes,  psychologies past and  present  be that William James , Sigmund Freud, Lacan, Perls or Ellis, Wachtel,  Carere and Zuckoff  etc… as it were… 

Something may be learnt from understanding  more about how this mind is embedded in a society in which certain coercive processes  may have shaped the client’s parents to  push the client  into particular roles, to adopt a certain way of symbolizing his or her experience which did, it would seem, do violence to their own meaning system, and where dialogical forms  …( Q2)  were replaced by ‘acting out’ or ‘enacting’ conflicts  behaviourally, ( Q3) The studies  which might ‘show up’ in Q3 may well  address very similar issues, but usually from within a different tradition and using a different vocabulary  for instance in the field  of  substance misuse or domestic violence  and there may not be  much cross referencing between the work of  Carlo Di Clemente and   Ronnie Laing even though they both accurately diagnose what is wrong and prescribe what may help. (There are more psychotherapies, Horatio, than you have ever dreamt of…) 

The study of institutions  and their effect on what we consider normal and desirable, the extent to which power structures  are designed to include or exclude and how this impacts on our clients experience and reality  will usually make a difference to whether we see certain behaviours as defenses against oppression, racism, homophobia or whatever, or as  the paranoid phantasies of someone on the verge of a psychotic breakdown, or indeed, a mixture of both! (Q4) or a drug induced temporary state ( Q3) .  DSM IV  etc  may effectively  screen for  general life conditions, an understanding of the health care system will help us locate appropriate pathways to care, health policy will address the politics of how to tackle inequalities etc,  all of which connects with  structure grams and statistics and sociological enquiry into public health related  factors ( Q4) but  we need to look to Q2 for  theory driven critiques of how we do describe and research such issues    informed by people such as Weber,  Foucault or Habermas etc… and to rule out  biochemical imbalances (Q3). 

 My personal experience has been that I have found extremely useful pointers to information  I needed to better understand my clients  in studies whose underlying assumptions I do not share at all, and whose methodology  I found in some way questionable.  A ‘re-analysis’, re-ordering- rethinking of ‘data’ presented   in certain studies would on occasion point me to an interpretation of findings quite different from those  elaborated by the authors in their discussion. This would usually put me on the trail of looking for other work  where, with luck, I might find studies or inquiries that were closer to my own preferences regarding assumptions and favoured methodologies,   providing me with some evidential basis for my intuitive  take on the client’s issues – that is provided I also took full account of  any countervailing evidence that would cast doubt on my currently favoured hypothesis…  

The four quadrants are really pointers to living webs of ever changing knowledge, skill, information, hypotheses, data, assumptions, hypotheses, etc that  have their centre of gravity on one tradition rather than another, quote a certain body of literature that has a certain coherence, rather than another.  

 I ask that integrative therapists should endeavour to consider- not cover- as that would be impossible- all four bases.  Most integrative therapists will have a  preferred home base  which brings with it in depth familiarity with a particular discipline, domain, universe of discourse, set of models and practices etc. All I ask is integrative therapist be aware  that this is so, and to respectfully look next door  with a degree of curiosity, and on occasion in genuine search of help ‘from outside’.  

The meta- framework  differs from many existing bio-psycho-social  models  in that it does not in itself offer a particular blend of psychological  biological, socio-cultural  bodies of knowledge and practice that could be set down in a textbook.  It is a tool for  acquiring such knowledge ( if a student) or for applying such knowledge ( for  seasoned practitioners) .  

Anyone who uses it would of course  use it to organize their own  core menu of questions asked about  decision making procedures which take into account philosophical inquiry  and  scientific methodology and that operate upon a core curriculum of findings about  human psychology and  development through the life span, dialogical processes  explored  through ethics, aesthetics and anthropology,  and an understanding of the workings of living systems  comprised of institutions, organisations and the natural world… 

 Once we have  acquired and organized  our own bases of findings, understandings  and practices  we ally for new journeys into unknown territory.  What we may ‘know’ today’ will always need to be live, constructed out of different facets, useful for a particular line of inquiry  relevant to a particular client, but there will be some family resemblance between  what integration we  achieve today regarding client x and what we  put together yesterday regarding client y  and what we  may construct tomorrow regarding client z.  There will be a family resemblance  between   what we do over time, we all have a signature tune, but if we are truly integrative we are forever composing new pieces and forever  innovating, yet  without loosing  our personal and professional   shape. We will be subject to the usual pressures of competing personal and professional responsibilities, bad hair days and other factors likely to impair our judgment- but the aspiration to do a reasonable job is always there…  

The purpose of the meta- framework is to  help us to research and inquire in an integrative fashion. What we need to know in order to practice  in an informed way, responsibly ,effectively, efficiently, and above all  wisely. 

The onus is on each  of us to examine whatever  we find  with careful regard to the underlying assumptions, both the assumptions  of the authors whose work we draw on, and our own. This means being  open about the inevitable fact that each of us has preferences, a default standpoint and certain historic allegiances. 

Conflict is healthy as long as it is not adversarial and ad hominem ( feminam) ,  but rather it is the motor  which drives forward a form of  collaborative  enquiry  where we openly compete with one another to find the clearest questions and the most well formulated answers to issues of common concern.

 We are openly and honestly advocating for our own synthesis, integration, analysis, truthfulness, accuracy of observation, ethical practice .  

This is called dialogue and it keeps the inquiry open to the future, ie, dynamic  and with a living  growing edge… 

 I am spelling many these issues out in more detail in a book which is ninety percent complete – you are welcome to have a preview – and I will illustrate this way of working at the Florence conference with a practical case example

Allan Zuckoff, 6 March 2006

Hilde,

 Do you remember the rubric quoted by Foucault from Borges that I used previously as an illustration? I had the same sense of disorientation when I read your line,  

<<psychologies past and present be that William James , Sigmund Freud, Lacan, Perls or Ellis, Wachtel,  Carere and Zuckoff etc… as it were…>>

Thank goodness for that “as it were”—otherwise I might have been permanently shifted into some unfathomable episteme within which such a sentence could be deemed comprehensible.

 With this notable exception, I believe I finally understand the nature and purpose your meta-framework, and all I can say is: it’s a fascinating model. Thank you for taking the time and effort to lay it out so clearly that even I can grasp it. I look forward to paying for and enjoying your book when it becomes available.

Tullio Carere, 6 March 2006

Allan, Hilde, Tyler, Zoltan
Hundreds or thousands of things happen in a session, all of which are idiosyncratically interpreted and responded to by both patient and therapist. Real therapy, as any genuine inter-subjective exchange, and as is clear to common sense and to Stern's Boston research group, is basically floppy (unpredictable), whatever the therapist's theoretic allegiance. Of course, from this intricacy one can extract all sorts of testable hypotheses, put them to test, produce procedures supported by those tests, and apply such procedures to the intricacy in the sincere conviction that this will improve the efficacy of real therapy. This is the scientific approach to psychotherapy, and I have nothing to object to those (therapists or patients) who feel more at ease in this sort of relational environment.
 
I, among others, feel more at ease in the common sense approach to psychotherapy, corresponding to the assimilative-accommodative integration. In this approach the therapists assimilate whatever theory or technique suits their taste or temperament, and bracket out as much as they can all their theories in order to accommodate as much as possible moment by moment the demands of the process. In the common sense approach protocol driven procedures are sheer non sense; but the common sense therapist feels compelled to produce objective material (mainly post session questionnaires and written notes by both patient and therapist), whenever needed, to monitor and document the process and to correlate process and outcome.
 
Ps. Tyler, thank you for saying  <<I suspect that the phenomenon that Tullio is referring to is more subtle than the research solution you are proposing, Allan", and "one of the flaws of analytic research was that in order to examine concepts with real construct validity, one was forced to stay close to the surface>>

Tyler Carpenter, 7 March 2006

Not sure I see the two positions as that dichotomous, Tullio. I think it may be the hypothesized mutual exclusivity and reducing the dialectic to anchor points that kills the discussion and the science. I think it fair to say that I can easily understand what I do in your framework. However, much research such as you describe is both the source of information on which I might base a medication referral or is the basis of a treatment protocol or ideology that my client is compelled to work with and which I can integrate if I broaden my understanding. Said a different way, I can practice as you say you do, but would lose much synergy for my patients if I neglected the contextualizing milieu or access to mood and thought modulators. Sometimes what I do is work with what others are doing or calling something and help my patient process the material therapeutically. In this respect perhaps I am more Taoist than Confucianist in my therapeutic sensibilities and pragmatism.

Allan Zuckoff, 7 March 2006

Tyler,

I agree that there are subtleties that would be difficult if not impossible to capture in controlled research. Hilde’s post suggests that there may nonetheless be ways of capturing at least some of the variance via traditional research methods. And this is precisely where systematic qualitative research may capture even more.  

A method I have used (in brief): record a therapy session of interest, break the tape into smaller parts, then invite the client to be interviewed about the experience of the session; offer instructions, play a tape segment, ask the client to describe his/her experience in the moment. Record the interview and have it transcribed, so you have the session segments and the interview segments linked. Do this with multiple clients, then use a disciplined methodology to first analyze each of the subjects’ experiences individually, then synthesize a general structure of the experience. This general structure is potentially replicable (or falsifiable), both through obtaining analyses of the same data by other researchers, and through repeating the analysis with data from other sessions/ other clients.  

What matters most, I think, is not the specific method we use; it is our willingness to subject our intuitions and fondly held beliefs to a test in which they can be shown to be wrong. It is simply too easy, otherwise, to believe what we wish to be true, because we wish it so.  

Tyler Carpenter, 7 March 2006

Fascinating methodology, Allan, and I agree that Hilde's framework has much to offer.

For me these days it is the non-verbal emotional resonances and dissonances (e.g., vocal tone, facial expression, posture, verbal-nonverbal discordances, etc.) that I find both crucial to effective work and fascinating to process. When I reviewed the extant models of brief therapy at a Mass General Hospital seminars about 12 years ago I found that they were quite limited in applicability to severely disturbed populations (except for Leopold Bellack's model which was not covered and which I learned in a seminar with Bellack in the early 70s). I later saw Si Budman present on his character focused model (about 20 sessions I think). When adapting to working in prison I found that not only did I need to become aware of multiple comorbidities in diagnostic formulations, the nature of the "average expectable environment", the adjunctive use of medications, but broaden my conception of what Martha Stark refers to as the principal modes of therapeutic action, e.g., interpretation, experience, and relationship. In such interpretation, re-education, support, exploration, behavior, modulation of drive/affects, etc., take on fine nuances and it is the sound and fury that signify what is important to attend to, as well as what it is important to interpret and how to frame it. I absolutely agree with you about the importance of submitting everything to careful scrutiny. I couldn't have unpacked some of the concepts if I didn't do so. If I wasn't up to my neck in clinical work I could look closer at the process than current time and resources allow.

Tullio Carere, 8 March 2006

As the Florence Conference approaches, it is time to draw up a first balance. The pre-conference discussion has taken place so far parallely on this listserv and on the Italian SEPI-list. On the latter Giovanni Liotti made a lucid point. Psychotherapy integration, he said, happens only on the ground of empirical research. On this ground psychotherapy is on its way of becoming a normal science, like biology or medicine. But the field is split: on the other side of the split there are those who refuse this integration. There is no other integration happening on that side, though: on the side of science integration is in progress, on the other side one finds only differentiation into myriads of school, group, or individual theories.
 
At this point of the debate I think that Giovanni is right. On the side of those unwilling to accept empirical science as the foundation of psychotherapy, the field is fragmented or pulverized by the joint effect of assimilative integration and eclecticism. As I pointed out earlier, assimilative integration is inevitable, inasmuch as we all go on assimilating pieces of other theories into our home theory through our all professional life. This paradoxical process is integrative at the individual level, but disintegrative at the field level. (As George remarked, an alternative to assimilative integration is eclecticism, which is disintegrative at both individual and field levels). The joint effect of assimilative integration and eclecticism is that there are almost as many psychotherapeutic theories as there are therapists in the room.
 
The differentiation of the field happening on the non-empirical side of the split would not be a trouble, were it balanced by the presence of a common ground, where common needs and goals were matched by common factors and strategies, and therapists could communicate among them on the ground of a shared common sense. On the ground of common sense, therapists could bracket out their pet theories and be able to dialogue with colleagues of different persuasions, and thanks to this dialogical space could change their minds and accommodate elements of different perspectives incompatible with their frame of mind. The integration would then be really assimilative-accommodative, not just assimilative with as little accommodation as possible.
 
Common sense, in which sound intuition and reason are balanced, is common to every human being, i.e. is available to anybody willing to conquer it; but on the other hand it is very uncommon, inasmuch as in order to conquer it one has to submit to a hard and permanent discipline like phenomenological epoché, Bion's freedom from memory and desire, or Gemma Corradi Fiumara's philosophy of listening. All these disciplines require the suspension of all preconceptions and expectations, which is experienced by the ego as a psychological catastrophe. As a consequence, none of these disciplines is very popular, almost no therapist puts one of them at the core of their dialogical approach and clinical practice. As common sense remains most uncommon and unpopular, common ground among therapists remains the bizarre utopia of 'common grounders', and the only integration really happening on the real ground is the one grounded on empirical research.

George Stricker, 9 March 2006

How about an integration that does not occur on one or the other side of the divide, but between the two poles, representing a real seeking of a synthesis?

Tullio Carere, 9 March 2006

George,
in a dialectical perspective no real synthesis is possible between a strong thesis and a very weak antithesis. The antithesis must grow, for a synthesis to be possible. The antithesis, to me, would be a full-fledged assimilative-accommodative integration. But how many would agree? Not many, I guess.

George Stricker, 9 March 2006

A full-fledged assimilative-accommodative integration would be my preference for an antithesis (and I agree that a strong one does not exist and is needed for a synthesis to occur). However, it is not the only option, and any one that might provide an antithesis would start the process off, and might even be the impetus for further development of antitheses.

Tullio Carere, 10 March 2006

George,
as a full-fledged assimilative-accommodative integration is the preference of both of us for an antithesis to empirically supported psychotherapy, and as we also agree that a strong one does not yet exist but is needed for a synthesis to occur, could we elaborate a little more on it, just to make it a little stronger?
 
Firstly, the assimilative side is precious inasmuch as it lets us tailor our theory on our tastes and preferences. My theory is an idiosyncratic summa of my history, personality and choices, nothing to do with manuals. I am free to choose the theories that best suit me, as the patient is free to choose the therapist that best suits him or her. In this perspective, the crucial therapeutic factor is the person of the therapist, not a technician who administers protocol-driven techniques. "As many theories as there are therapists in the room" is no longer a mark of weakness, but a sign of freedom and pluralism.
 
Secondly, the accommodative side makes me bracket out my theory all the time in order to get tuned with the demands of the process. It is the reciprocal of the request I make to my patient to suspend his or her convictions to have our dialogue progress. It means that the focus of therapy is dialogue, not a disorder to diagnose and treat by means of empirically supported procedures. Genuine dialogue happens when and to the extent that both interlocutors let go of their respective convictions -- personal, ideological, metaphysical, theoretical, whatever -- and rely on nothing else than common sense.

In sum, assimilative-accommodative integration means that the focus of therapy is on interpersonal relationship and dialogue, not on scientific proceedings (though science has some room in it, especially in the form of the local scientist -- as of course in ESP there is some room for dialogue, but the focus is not there). I see assimilative-accomodative therapy and ESP as two different and incompatible things, one basically dialogical and heuristic, the other basically epistemological and protocol driven. The great divide reflects a real difference. It seems to me that before trying to make any synthesis between the two, it would be necessary to firmly establish the autonomy and independence of one another as two distinct disciplines. It is too soon for conciliation. Reciprocal acknowledgment and respect come first, in my view..

George Stricker, 10 March 2006

Tullio,
I hope that it is not too soon for reconciliation, and perhaps the key is in your statements about ESPs. Generally, I agree with you, and feel that they are limited and limiting. However, I do not equate science or scientific contribution with ESPs. There are many other epistemological approaches to research, such as practice networks, effectiveness research, systematic case studies and N=1 approaches, and so on. If we expand our notion of research, we also can expand the possibilities of a synthesis (or at least I hope so).

Zoltan Gross, 10 March 2006

Dear Tullio and George,  Underlying your theories of both dialectics and basing psychotherapy on empirical science is the assumption that we are all examining the same "elephant" of psychotherapy and that we are all speaking to one another in the same "language" about our discoveries of the parts of the elephant we are exploring.  I don't believe there is a single psychotherapy, which is the implicit assumption of the discussion. While it might be true that a cognitive behaviorist and an analytic therapist might both be successful in alleviating the anxiety of the person with whom they are working, I seriously doubt that personalities of the persons being treated wind up in the same place. The cognitive behaviorist's work has little to do with character structure.  On the other hand, analytic work, relational or transferential, does alter the emotional structures of the people with whom they work. I believe there are different psychotherapies serving different personal goals.  The Dodo bird awards are only given to the experiential end results of therapeutic work.  Prizes are not awarded for personality change.  Which brings me to my second point, so far empirical research does not have a common language with psychotherapy about the definition of personality, emotion, self, cognition, or consciousness.  The words used by both systems are the same but they speak different languages. The words don't mean the same things in the different systems. As a matter of fact, in a recent article by the president of APS declares that research in personality and psychotherapy are so different that they will never meet.  He ended his comments expressing his belief that this was the way it should be.  Unfortunately, not only are we blind in our examination of the elephant of psychotherapy, but when we communicate our findings we don't speak the same language. While assimilative integration is an agreeable hope, I believe it is very unlikely until we get past the pre-paradigmatic stage of knowing that George recognized

George Stricker, 10 March 2006

I think that Zoltan's metaphor about the elephant is well taken, and agree that the issue of therapeutic goals is often overlooked when comparing therapeutic outcomes. It makes as much sense to speak of "psychotherapy" as it does to speak of "medication" or "surgery."

Tullio Carere, 11 March 2006

George, Zoltan,
I see a variety of animals, not just elephants. But in this variety I believe to perceive a sort of order. Some animals are elephant-like, or strive to look like elephants, the most powerful animals of all.
Others are cat-like, much less powerful but proud of their cat-ness, and not willing at all to look like elephants. Then there are of course all sorts of intermediate forms. Sure enough, they are all mammals. But for the time being to concentrate on the general mammalian structure risks to make us lose sight of the substantial difference of at least two main species, as I see them: the species of
those who are fascinated by science (all sort of scientific research, not just RCT), and believe that science has the last word in deciding what is valid and what is not in their practice; and the species of those who have a moderate interest in science, but are much more interested in interpersonal interaction governed by genuine dialogue (which requires the sacrifice of all preconceptions and myths, the myth of science included). It seems to me that cats are an endangered species today, at risk of being crushed by the elephants' stampede. We should protect poor cats.

Tyler Carpenter, 11 March 2006

Perhaps a first step for such an  integration to begin to occur, George and Tullio, is to set up some tentative conditions and parameters: Many  discussions on such topics are so wide ranging that although they discuss the broad issues, there is much time spent on discussing the fine points of mutually accepted dynamics, e.g., the acceptance of a need for research & clinical thinking/experience, the idiographic and the nomothetic. By finding  a limited consensus on a topic and some sufficiently representative participants to discuss it, you have both a goal to be refined and a constituency to address the question.

Tyler Carpenter 11 March 2006

Zoltan Gross wrote :

<<Dear Tullio and George,  Underlying your theories of both dialectics and basing psychotherapy on empirical science is the assumption that we are all examining the same "elephant" of psychotherapy and that we are all speaking to one another in the same "language" about our discoveries of the parts of the elephant we are exploring.  I don't believe there is a single psychotherapy, which is the implicit assumption of the discussion. While it might be true that a cognitive behaviorist and an analytic therapist might both be successful in alleviating the anxiety of the person with whom they are working, I seriously doubt that personalities of the persons being treated wind up in the same place. The cognitive behaviorist's work has little to do with character structure.  On the other hand, analytic work, relational or transferential, does alter the emotional structures of the people with whom they work. I believe there are different psychotherapies serving different personal goals.  The Dodo bird awards are only given to the experiential end results of therapeutic work>>

I suspect the issue is not so much whether we are using the same language, Zoltan, because it seems as though we are. The language is English. However, we do at times move fluidly between professional vocabularies and our understanding of them and this tendency to do so makes the discussion both more personal and in ways perhaps more undermining of an attempt to develop a common assimilative- accomodative framework that both accrues certain agreed upon and shared structures (nomothetic) and terms, while also allowing for individual divergencies (idiographic) in structures and meaning. There may be no single psychotherapy in the narrowly defined sense, but there are ample examples of common practices or ways of being therapeutic that are clearly supported by empirical literature or easily discerned by translating terms and structures and processes from one framework to another. This last point leads to my next one:

I think to draw the distinctions you do about cognitive vs. analytic approaches to anxiety and character is to make the approaches more separate than they actually are in practice and to talk about how a process may be described rather than how it may in fact occur in terms of both frameworks. To take the example of addressing anxiety using both frameworks, there is nothing that would suggest to me that either framework neglects the role of  personality and its relationship to anxiety. And broadly construed there is nothing that suggests to me intervening cognitively has any less or more to do with character and symptom in one framework as opposed to the other. Both disciplines utilize interventions of a cognitive nature aimed at changing the relationship of understanding of symptom to personality context and while the vocabularies and timing may differ, with an understandable difference (perhaps minimal) difference in change in the individuals involved, this is as likely to be something found within a group of analysts or a group of cognitive behaviorists talking about how they do what they do.

 I think it was Roy Schafer who attempted to deal with a similar cacophony and chaos in the analytic community by writing a book on changing the language used to describe therapeutic change(perhaps more accurately professional terminology) that focused on what is actually done rather than spending time sorting out specialized terms and constructs that become a source of contention among groups trying to discuss (at least on one level) what they are trying to do in their work. Said a different way, both analysis and cognitive therapies agree that distortions in perception are anomalies in ideal adaptations to the world and focus on these anomalies is central to the process of restoring a relative functional adjustment with respect to cognitive-affective and interpersonal function. One group calls such anomalies cognitive distortions and the other calls them defenses. Useful dialogue may proceed from laying out and discussing how these terms
differ in assumptions they imply as well as in how their role may be addressed both in theory and practice of restoring function in patients. When this happens it becomes quite clear that there are often differences within professional groups that are as profound as between groups with respect to how the individual practitioner makes use of the structures to address the problems at hand in the treatment.

Tyler Carpenter, 11 March 2006

However, Tullio, such a distinction seems to be as much about how you choose to use the terms and bound the discussion (see Lewis Carroll's quotation from "Through the Looking-Glass." on how and what words mean and are chosen to mean), as it does about the data and processes involved. The results of the research that undergirds ESPs is as likely to be  heuristic and provisional and reflective of common sense, and hence to be assimilated and accomodated by the local-scientist, as are the results of a common sense focus on the person of the therapist in the therapeutic dialectic For example, see how Ebbinghaus' personal observation of his memory has stood the test of time. We are talking in large part about preferences in the qualitative characteristics of methodology and not necessarily about what each method produces for assimilation and accomodation by whoever and whatever we choose to call the common model (which I submit is not a bad way to describe it and avoids the superfluities and pitfalls of double-think - call one thing by another set of terms). To be a little subversive, I suspect that if we were not to discuss where we got the data we are submitting to the process, it would be damned difficult to determine whether it was from ESP research or self-other clinical observation. Perhaps that is a better way to proceed and thus dispense with the question of determining first whether something had a previously determined authenticity and then second whether and how it could be assimilated and accomodated in a larger and agreed upon framework.

Tullio Carere, 11 March 2006

Tyler, I am not sure that I understand what you say. What I say is that there are two basic attitudes among therapists: one is theory-centered, the other is dialogue-centered. The theory-centered depends on empirical testing, the dialogue-centered depends on the training of the capacity of genuine listening. The first discipline is much more popular these days. I have tried hard, years long, to reconcile these two attitudes (the first SEPI-Italy conference, 2002, was the highest point of my efforts in this direction). Now I have given up, I don't think any longer that these two attitudes can be reconciled. Not in this phase of development of psychotherapy. Not until the dialogue-centered becomes a strong enough antithesis to the theory-centered.

Tyler Carpenter, 11 March 2006

I would both make myself clearer and amend your position as follows, Tullio: Two of the basic attitudes that therapists consider are theory centered and dialogue-centered. Theory and dialogue can both be empirically tested (formally as in a "scientific" study) or individually tested as in careful and thoughtful observation of dialogue. Both approaches are characterised by careful listening and attention to the variables involved. The zeitgeist is predominated by the former methodology.
Sometimes people resist being put in a box and having data systematically excluded from discussion and integration. I couldn't survive and thrive in prison if I engaged in drawing overly exclusive distinctions. That, and not punitive ideology and maladjusted personalities, are the primary reasons psychology and psychiatry haven't historically flourished in these environments. Sorry I can't be in Florence. I hope we get to meet in person some day. If you enjoy a thoughtful beer (not just the discussion accompanying the drinking, but the way  the beer is crafted), I suspect
you'd enjoy sharing one of my homebrewed beers. "St. Feullion's", the Belgian Tripel I just finished is great! The development of psychotherapy, by history and nature, has always been non-linear and proceeded on multiple fronts.

Tullio Carere, 11 March 2006

Thank you Tyler for clarity and amendment. I understand that people don't like being put in a box. Yet concepts are boxes, aren't they? Can we do without concepts if we want to reason? But let us try to use our boxes judiciously. Both the theory-centered and the dialogue-centered therapist have their own theories, but the difference is that the former is highly motivated to apply rigorously their theory (from which their professional identity usually depends: I am a "Gestalt therapist", or a "Kleinian psychoanalyst" inasmuch as I am true to the theory of my school or group): whereas the latter is much more motivated to bracket out their theory (from which their identity depends much less) for accommodating whatever in the relationship with their patients resists being assimilated by them.
Even if the theory-centered therapist is not a school therapist, but a conscientious therapist willing to apply empirically supported theories and techniques, she knows that she cannot empirically test
her theory inside the session: she has just to hand her material over to professional researchers, who will give her in exchange the last empirically supported theories or techniques to apply. Quite another story for the dialogue-centered therapist: she is a researcher and a local scientist in her own right, she uses moment by moment the feed-backs she gets in the relationship for adjusting her theory.
Finally, both the theory-centered and the dialogue-centered therapist are interested in the external validation of their work. But the methods are quite different, whether or not one chooses to call them "empirical". The theory must be transformed in a protocol and studied in an experimental setting. The dialogical therapist must produce objective material, like recordings, post session questionnaires or written notes by both patient and therapist to document their work. We have nothing to gain, I believe, if we mist and blur these basic differences for fear that someone feels being put in a box.

Tyler Carpenter, 11 March 2006

You're welcome, Tullio.
For me, box in this context is a rhetorical device. Concept is neutral language/vocabulary. If I think outside the box or come out of the box (both of which metaphors are good descriptors of my behavior that are highly congruent with how others would describe me and how I behave) those describe how I respond to being restricted in my thought and behavior. I see your point about identity or self. This concept comes in various kinds and sizes and neither implies narrowness or excessive (or any) reliance on empirical proof. In fact in the narrow sense excessive boundedness by parochial or personal definitions might be seen by some as on a continuum or a dimension with a more open and inclusive sense of who one is .So as we play with the concepts things don't appear to be so exclusive and the opportunities for dialogue and understanding and integration can expand.
Whether one practices in one setting or another, the issue remains methodologica

l and there is no corresponding theoretical mandate to surrender control of ones evaluative processes, though others may choose to see us differently (and there Einstein's thinking may have much to offer our discipline about the nature of relativity). As for external validation, different folks require different kinds. In the prison, most everyone demands that the individual who talks the talk walks the walk. Whether you get there by introspection or journal reading, results everyone can see and live with is the only real measuring stick accepted by all, whatever they call themselves and whatever role they fill. I think the concept of fuzzy boundaries is not only a pragmatic approach, but a part of the conceptual tools of modern mathematicians, but then I'm way over my head when it comes to that particular application.

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