George
Stricker 11 March 2006
I'm not sure that I see the basic
distinction as between the theory-centered and the
dialogue-centered therapies. As you quite appropriately
note, both need external validation. The question is
whether we look to laboratory science or local science for
that validation, and my point is that the operative word
should be "and" rather than "or." For the theory-centered
therapist to reject data from the local clinical setting
is silly; for the dialogue-centered therapist to reject
data from more tightly controlled studies is equally
silly, in my mind. Each has something to contribute to
knowledge, and each has weaknesses that limit what they
can teach us. If we can learn what they have to offer
while keeping in mind where they fall short, we may be on
the road to a more sound knowledge base.
Tullio Carere, 12 March 2006
It obviously would be silly to reject
useful data, wherever they come from. The question is: are
laboratory data really useful to the dialogic therapist?
The low-to-null external validity (applicability to
therapies in the natural context) of laboratory data has
been pointed up many times, and can be easily explained by
the fact that laboratory data refer to protocol driven
treatments, whereas in the natural context therapists are
inclined not to work in the protocol mode, unless they are
inexpert, insecure, or bound by time-limited or otherwise
altered settings, because laboratory treatments bear only
a pale resemblance to real treatments. Peterfreund
introduced the useful distinction between heuristic and stereotyped therapists. Heuristic
is akin to dialogic, stereotyped is the therapist who uses
standard, manualized procedures. Laboratory data are
perfect for the stereotyped therapist, but I would hardly
say the same for the heuristic or the dialogic. I, for
one, don't remember having come across a single laboratory
finding useful for my everyday work in more than three
decades of professional (not academic) life.
George Stricker, 12 March
2006
I'm not going to defend manualized
laboratory work, as I am well aware of all the
limitations. However, if we use more standard research to
explore principles of change rather than the impact of
specific interventions on artificial groups, there is much
more that can be learned.
Tyler Carpenter, 12 March 2006
Tullio, it's hard
for me to imagine how a manual driven approach or a study
of say a systematic desensitization or implosion therapy
approach to dealing with a feared object couldn't be
productively integrated into a dialogic approach. First,
because there is more consistency between the application
of Lab and real life applications (the goal of such
approaches is just such a veridicality); and, secondly
because a dialogically oriented therapist could tweak or
adjust the application precisely because the feedback was
so readily available either in the derivatives or manifest
behavior (including non-verbal behavior).
Case in point
(and understand I generally eschew labelling myself in any
particular way): I was trained in EMDR and have read and
listened to much on paradoxical therapy. Though I think in
my therapeutic niche a complete integration of protocols
for these approaches is not always possible or even
desirable, I have no trouble incorporating the principles
in my work (e.g., close attention to eye movements and
nonverbal reactions when processing traumatic material,
including character embedded transference; response to
paradoxical suggestions in the context of ongoing
therapeutic dialogue). In fact it is precisely the fact
that I work this way that allows me the flexibility you
say only belongs to the person who labels himself a
dialogic therapist. It sounds to me like you are
suggesting throwing out the entire set of results of
empirical treatments, which themselves are only ostensibly
controlled amalgams of the components we all use and pay
attention to when we work. Said a different way, one might
even characterize certain therapies, especially the
research based ones, as hypertrophies of factors that are
an element in all therapies.
Finally, if I remember my history
correctly, the reason that manualized approaches were
developed was not to substitute them for a more
idiographic approach, but to control the relevant variance
and compare the active ingredients in studies that were of
ostensibly different therapies. In fact, the authors of
the manuals (Hans Strupp, Lester Luborsky, Aaron Beck)
used in research were generally analysts (Menninger or
Topeka, and Washington School of Psychiatry?) by training
and history that were putting the products their clinical
training to the formally empirical test. In fact, for
years they were the only type of psychologists that were
given full and validated training sanctioned by the
American Psychoanalytic Association. The manuals served
the dual purpose of research protocols and training tools
for their students. However, the best source for
explaining this history is likely SEPI members Mo Parloff,
Irene Elkin or Barry Wolfe (who used to head NIMH's
Psychotherapy Research Branch) or the authors themselves
who I believe are on the Board of Advisors for SEPI, right
George?! Wasn't Peterfreund also an early researcher on
sex offenders?
Finally, the question is not
just is the hypothetical gap between researchers and
dialogic clinicians, but between members of the supposedly
same therapeutic schools of thought? Before there were
psychotherapy wars between different schools there were
conflicts between those who formed the separate schools
(initially sects to be precise). A senior colleague once
told me that Lacan once analysed someone who had been
treated with ECT. Now if that isn't simultaneously
dialogic and research driven, I don't know what is.
George Stricker, 12 March 2006
For history, Tyler, every one you
mentioned has been a SEPI member, at least, and in Barry's
case, even is on the Steering Committee. My memory about
the origin of manualized treatment is to ensure treatment
fidelity - that is, that people who said they were
investigating a brand of therapy really were doing it. Of
course it then expanded into a prescription for future
treatment, but that is another story.
Barry Wolfe, 12 March 2006
Just to amplify George's remarks, the
NIMH made a decision around 1976 that to study
psychotherapy was to study the specific techniques of
psychotherapy. The behaviorists had shown us with
manuals developed in the early 1960's that therapy
techniques could be operationalized and manualized.
This decision came on the heels of two decades of
NIMH-supported outcome research on so-called "traditional
psychotherapy" and no one knew what that really
meant. In order to insure treatment fidelity, as
George says, and to increase the interpretability of the
outcome data, the requirement was introduced that grant
supported psychotherapies need to be manualized.
Moreover, a manualized psychotherapy was viewed as the
closest thing to a standardized medication which would
then allow comparisons of research findings from both
psychopharmacological and psychotherapy studies. The
status of a given psychotherapy was based on how well it
compared to a medication in reducing symptoms of specific
disorders.
By the way, I vigorously
fought this sea change in what was called "fundable
psychotherapy research" because I knew it sounded the
virtual death knell for psychotherapy process
research. I
lost!!
Tullio Carere, 12 March 2006
Tyler,
I
assimilate all sorts of behavioral and even
pharmacological procedures into my psychodynamic home
theory inasmuch as my focus is never on the procedure
itself, but always on the metaprocedure, i.e. the way a
therapeutic action is experienced by the patient here and
now. In other words, my focus is always on the meaning of every therapeutic
interaction in the actual context, never on the meaning
the same (inter)action is given somewhere else, a lab,
Freud's office, whatever. I pick up therapeutic
suggestions in a completely heuristic way: "Someone
reported that this procedure could help in cases similar
to the one I am treating, let us see what happens if I try
it here". As much as possible, I apply procedures that I
have experienced on myself: beyond my analytic training, I
have had many therapeutic experiences in different
approaches (for instance, I too had an EMDR training in
Philadelphia). But in every case I am guided by common
sense, not by manuals, in the application of a procedure,
and I am totally unimpressed by lab results: I use a
procedure only if I have experienced it on myself or am
persuaded by the description of somebody else who has
employed it.
As an example, let me describe the way
I integrate psychopharmacology in my approach. I am a
psychiatrist, and have learnt to use psychotropic
medicines in the years of my residency and working four
years in a psychiatric hospital. When I left the hospital
and started a career as a psychotherapist in private
practice, thirty years ago, I never prescribed medicines,
because the Zeitgeist of that time did not allow it. When
I thought that a patient needed medicines, I referred her
to a colleague. By and by I learnt that to integrate my
work with that of the psychopharmacological colleague was
more complicated than to integrate psychopharmacology
myself. Now I quite often prescribe medicines, above all
antidepressants, but only in the context of a
psychotherapeutic relationship. I have no experience of
these drugs on myself, but the experience of other
colleagues and of many patients is persuasive enough of
the usefulness of these medicines. Laboratory data should
be more compelling in this case than in the case of
psychotherapeutic procedures: in fact they are equally
ambiguous and not compelling at all. According to some
meta-analyses, the effect of antidepressants is not
significantly different from that of active placebo. Dodo
bird rules here too.
My personal opinion is that
antidepressants do have a significant pharmacological
action, although the placebo effect is very high. In any
case, when I prescribe an antidepressant its specific
action is never in the forefront in my mind, as with any
other procedure. I can propose an antidepressant when the
patient says that she feels too bad and believes that
psychotherapy does not help enough. Like Hilde, I have my
own heuristic mandala, a four-vertex model to orient
myself in the therapeutic relationship. The horizontal
axis connects the maternal-accepting and the
paternal-confronting vertices. On this axis, the proposal
of an antidepressant can be experienced as an empathic
understanding of her suffering and an attempt at relieving
it (maternal vertex), or as a confrontational
intervention, something like "if you are not collaborative
enough, I'll have to give you a medicine" (paternal
vertex). My heuristic model helps me understand the
patient's experience of the prescription (the
metaprocedure), but then I put even my mandala aside in
order to listen "without memory and desire". This is an
example of my assimilative-accommodative approach, in
which manual driven approaches have no place at all. I
hope this helps our dialogue.
Tyler Carpenter, 12 March 2006
Although I am not a psychiatrist,
Tullio, I clearly work and assimilate techniques and refer
to/consult with our psychiatrist in ways quite similar to
you. We don't describe some of the ways we label what we
do the same and in this we are congruent with much of the
empirical literature that shows that whatever therapists
call what they do, in many ways they are quite similar in
their actions. Thank you for sharing your rationale in
such detail. I find it very confirming of my approach as
well, though we clearly differ in some of the ways we talk
with others or discuss it.
Hilde Rapp, 13 March 2006
I just want to pick
up on a few strands
1.
The
relationship between goals and outcomes: for me what links
these are values. Values help to shape the outlook
which informs how we define goals, what means are
acceptable and therefore what outcomes we seek to bring
about.
2.
manualised therapies: as Barry reminds us, the
original purpose of manualised therapies was to design a
form of standardized ‘treatment’ that could be researched
by methods favoured ( still) by governments who have
to account to the public that they spend taxpayers money
on treatments that are cost effective. The manuals become
useful for training therapists and to test whether they
are compliant – ie deliver the ‘treatment’ that had been
found to be cost effective in scientific trials
correctly, and thus effectively.
3.
character
change: almost by definition, complex client
‘problems’ require complex therapeutic ‘solutions’.
Complexity almost always goes hand in hand with
uncertainty, unpredictability, making ‘ one problem-
one solution’ scenarios unlikely. Therefore , manualised
therapies which work in ‘one problem- one solution’
situations- for which they were designed, are unlikely to
be able to deliver change.
A more art and
skill and tailor made intuitive approach is likely to be
needed which will work with the resistances and conflicts
that are part of the clients ‘mal’-adapted
responses to ill understood challenges. The
first therapeutic task may be to discover how the
client understood, construed, interpreted a life
challenges and what behavioral repertoires he/she had at
their disposal to respond to this challenge at the
developmental juncture and in the familiar relationship
context in which they found themselves at that time.
Expose to unusual challenges over
a long period is likely to lead to character-‘de’
formations which drive a range future ‘schema
based’ behaviours which may not have a coherent
surface structure but nonetheless share a common root,
which if addressed then helps to undo the apparently
chaotic branches.
4. Dodo- bird-
horses for courses : I know what follows is crude-
but I do think that there is a
relationship between the
complexity of client problems and the complexity of
treatments designed to address them.
I think that
it is fair to want to spend public money cost
effectively, and that this might mean that we
recommend a symptomatic standardised ‘treatment’ as
a first response to what looks like a symptomatic simple
response: “every time I am scared I overbreathe and get a
panic attack.”. If “every time I am scared “resolves
into “every time I am scared of x- and almost only when I
am scared of x”, then a deconstruction of that
perceived threat into a decision tree with a
new repertoire of adaptive responses may be a perfectly
good way of helping this person overcome the problem
that brought them into therapy. Such a procedure can be
taught to a number of health professionals
during a short and inexpensive training via a
manual and they can carry out a procedure competently
which will help a large number of people with
such ‘simple’ panic attacks.
If it
turns out that such a procedure fails , a more
highly trained professional may need to reassess
the client and may then uncover
‘generalised anxiety with an underlying ‘neurotic’
character structure’ which will require
a more expensive therapeutic response by a more
highly trained professional who is competent in
‘negative capability’, deep listening, suspension of
preconceptions, intuitive tailor made empathic responses
and perhaps above all the capability to emotionally
contain, hold, transform or manage considerable
anxiety and aggression in the patient/client…
In short: I believe
there are families of approaches which may be
theoretically diverse within the family, but where
families are characterised by a reasonable
match between client and therapist factors which
revolve around the
complexity
severity
chronicity
intractability
of the client’s
difficulties as well as client factors such as
psychological
mindedness
intelligence
social
connectedness
temperament and
personality so forth
Clients who are
temperamentally non compliant may not respond to a
treatment or a professional normally adequate
for addressing the problem itself and they are likely to
need a much more experienced and resourceful
therapist with the skill to engage the client
in the first place and the resources needed
to prepare the client for such a treatment by
working first with characterological issues.
Allan Zuckoff, 13 March 2006
Tullio wrote:<< …in the natural context
therapists are inclined not to work in the protocol mode,
unless they are inexpert, insecure, or bound by
time-limited or otherwise altered settings, because
laboratory treatments bear only a pale resemblance to real
treatments>>.
Dear All,
It’s hard for me to
say this without being as offensive as Tullio, which is
not my intention, but I don’t get the sense that those on
this thread who are criticizing manualized treatments have
much actual experience with them. Though it’s certainly
possible to write a manual badly—that is, to provide a
rigid, simplistic series of steps the therapist must take,
which can be performed by any semi-competently trained
technician, and which ignores critical common-factors
therapeutic skills including capacity for empathy,
alliance-building, flexibility, etc.—I have not personally
been involved with such projects. I have, however,
provided protocolized treatments in open pilot and
randomized studies of supportive-expressive therapy,
complicated grief treatment, motivational interviewing,
and interpersonal psychotherapy. I have also written and
adapted manuals in a couple of these areas. And here are a
few of the things I’ve experienced and learned:
- Doing manualized
complicated grief treatment, which integrates a
modified-exposure-based CBT treatment with elements of
interpersonal psychotherapy and a little motivational
interviewing, was among the most challenging and
rewarding experiences of my professional life. Despite
being a fairly structured treatment, it also required of
me the skillfulness I have developed over 15+ years of
psychotherapy practice. And, not only did it
quantitatively outperform interpersonal psychotherapy,
which (as many of you will know) is a much
less-structured therapy that most dynamic therapists
would not find unfamiliar, but my personal experience as
therapist was of participating in remarkable
transformations in clients’ lives in startlingly little
time.
- Doing
supportive-expressive psychotherapy with cocaine addicts
(in NIDA’s collaborative trial) would have been less
difficult and more effective if the manual and manual
supplement we were provided were a bit more specific and
mutually consistent.
- Learning and
practicing semi-structured motivational interviewing has
made me a better dynamic/humanistic therapist (and I was
pretty damn good already).
- Many (if not
most) practicing therapists would benefit from the
discipline, fresh thinking, and humility required to
learn and integrate a new, manualized treatment.
I also am
acutely aware that this “dialogue” has been lacking much
input from others on this listserv who view therapy
manuals and randomized controlled trials not (of course)
as the be-all and end-all of psychotherapy research, but
as one approach that can provide important information (if
complemented by process and qualitative research). If this
is the best the SEPI listserv can do, then what are the
prospects for dialogue among therapists of multiple
persuasions in the wider world?
Paul Wachtel, 13 March 2006
Dear Allan.
I agree with
you that manualized treatments need not be as simplistic
and limited as they are sometimes portrayed. And it
may even be, as you suggest, that at least some
manuzlized treatments provide benefits over and above
those of doing similar work in a less structured and
predictable way. But that is an empirical question, and the
problem with the way that manuals have become fetishized
in the field is that the more extreme advocates of
manualization have insisted that only with a manual can an
outcome study provide valid information about the
effectiveness of a therapeutic approach. Backed by
the political and economic power of managed care companies
and other representatives of the "cheaper is better"
corporate approach to health, research funding sources too
are hesitant to fund outcome studies that do not include
manuals. This, of course, makes it impossible to answer
(or even pose, except hypothetically) the empirical
question. How can you compare a manualized treatment
with a non-manualized treatment if only a manualized
treatment can be included in funded research? The
rules are tendentious. They stack the deck. They
imply, by
definition that a non-manualized treatment cannot be "empirically validated"
since empirical validation, according to these skewed
rules, requires manualization.
It is both illogical and logically airtight, and the
conclusions are foregone ones.
So I don't have any
disagreement with your own arguments, which really are for
a measure of mutual respect between
proponents of different paradigms, different procedural
inclinations, and different visions of how the need for
some kind of empirical validation is to be pursued.
But I have a great deal of disagreement
with those who, in a mix of subtly (and not so subtly)
disguised ideology and self-interest insist that outcome
studies that do not employ manuals are either or both
unfundable and invalid. That is politics, not
science.
Allan Zuckoff, 13 March 2006
Dear Paul,
Thank you for your
response. I agree without reservation with every word you
have written here. I believe that researchers need to be
able to describe the therapy they are testing, and provide
some way of ensuring that the therapists doing the therapy
are doing it well and with integrity (true to the
approach). Manuals and their accompanying
adherence/competence scales are only one way of
accomplishing this, but politics (or perhaps ideology) has
cursed the field of psychotherapy research for decades
with mutual disrespect and polarization.
In fact,
here’s a tantalizing tidbit from an area I know very well:
in a meta-analysis of controlled studies of motivational
interviewing (MI), Hettema, Steel, & Miller (2005)
compared studies of MI that did and did not use a manual
(amazingly, a number of non-manualized studies have gotten
funded by various sources). The overall effect size for
manualized MI = 0.35; for non-manualized MI, 0.65. At
least part of the explanation for this comes from a study,
led by Bill Miller (the developer of MI), in which (he has
since publicly concluded) he did a poor job of writing the
manual, by insisting that all patients receive a certain
element of the intervention whether or not they were ready
(a clear violation of MI principles). So it may be that
some kinds of therapy are interfered with if done
according to a manual, while other approaches are aided by
manualization; or that some manuals are better than
others; or that how one teaches a therapist a manualized
therapy influences how well that therapist performs it;
and so on. The complexity is great, and clearly one answer
does not fit all circumstances.
George Stricker, 13 March 2006
I would like to add
one point to Paul's comment, and it is from the standpoint
of someone who respects data and would like to see science
contribute more to practice (and vice versa). RCTs, which
are held up as the gold standard, and certainly are very
powerful in terms of internal validity, almost always have
symptom change as the criterion. This is not necessary,
but it seems to work out that way, and it does give the
apparent advantage to treatments that focus on treatment
rather than relationship pattern or character change.
Allan Zuckoff, 13 March 2006
Dear
George,
I agree
wholeheartedly with your comment as well. To paraphrase
(or in this case, butcher) Nietzsche again, a philosophy’s
most vociferous adherents should not be seen as evidence
against it.
Tullio Carere, 14 March 2006
Dear all,
I apologize for having expressed my
dislike for manualized treatments in a way that has been
perceived as offensive by someone who likes them, as
Allan. I'll try to reformulate my ideas on this topic in a
more respectful way.
A key concept in my view is that of metaprocedure (the patient's
experience of a procedure). The basic point is that the therapeutic factor in
psychotherapy is not the therapist's behavior (whether
or not one calls it procedure), but
the meaning the patient gives to the therapist's
behavior and the interaction in which it is embedded.
This is partially true already in medicine, although here
the patient's subjective experience is disregarded as
placebo, and only the "specific action" is considered. The
separation of the objective from the subjective component
of a therapeutic act is questionable even in medicine, but
is definitely weird in psychotherapy. Manualization of
psychotherapy is an imitation of objective medicine, which
implies the separation of the active ingredient (the
manualized procedure) from the placebo (the patient's
subjective response). The idea that a therapist should not
regulate his or her interaction as a function of the
feed-backs they uninterruptedly receive by the
relationship, in other words they should not be true to
the process as it unpredictably develops moment by moment,
but to a manual written by a well meaning researcher,
creates a new thing that I would hardly still call
psychotherapy.
The real thing to me, the thing I call psychotherapy, is
process-oriented. But the Zeitgeist has invented a new
thing, procedure-oriented, that many choose to call by the
same name of psychotherapy, because of a superficial
resemblance. Yet the new thing is not only a radically
different thing, but I dare say a mortal enemy to the old,
as Barry clearly enough observed:
<<…a manualized
psychotherapy was viewed as the
closest thing to a standardized
medication which would then allow
comparisons of research findings from
both psychopharmacological and
psychotherapy studies. The status of a
given psychotherapy was based on how
well it compared to a medication in
reducing symptoms of specific disorders.
By the way, I vigorously fought this
seachange in what was called "fundable
psychotherapy research" because I knew
it sounded the virtual death knell
for psychotherapy process research.
I lost!!>>
Process-oriented therapy is complex.
As Hilde notes,
<<Complexity almost
always goes hand in hand with uncertainty,
unpredictability, making ‘ one problem- one
solution’ scenarios unlikely. Therefore , manualised
therapies which work in ‘one problem- one solution’
situations- for which they were designed, are unlikely to
be able to deliver change.>>
It requires
<<a more highly
trained professional who is competent in ‘negative
capability’, deep listening, suspension of preconceptions,
intuitive tailor made empathic responses and perhaps above
all the capability to emotionally contain, hold, transform
or manage considerable anxiety and aggression in the
patient/client..>>
Now, Allan, why should you take
offence if I say that manualized "psychotherapy" is a
totally different thing as process-oriented psychotherapy?
And that I cannot see any possible dialectical synthesis
between the two? Manualized psychotherapy is a process
killer (but it is not easy to kill the process, as the
Dodo bird knows well). Yet I can accept that in some or
many cases a rapid symptom reduction could be desirable
regardless of the development of a psychotherapeutic
process, and in these cases a manualized psychotherapy
could be a viable alternative to medication. Therefore, I
don't object to the existence and the possible usefulness
of manualized psychotherapy: I only object to the
unfortunate confusion between the two things.
Is this
contribution more palatable? I am afraid not. Sorry, at
least I have tried.
Luca Panseri, 14 March 2006
Allan Zuckoff wrote
:
<<
Many (if not most) practicing
therapists would benefit from the discipline, fresh
thinking, and humility required to learn and integrate a
new, manualized treatment
>>
Allan, this
is an interesting point I have thought of a lot of times.
I often tried to approach some manualized treatments but I
was never able to read and practice them thoroughly. I got
bored, annoyed and above all I found them too distant from
what Tullio calls “real treatments”.
Honestly I
often asked myself whether my attitude towards
manualized treatments was due to a lack of
discipline and humility for my part.
For example, as many others on this
listserv, I got the EMDR certificate but it was a real
pain. I couldn’t do and say what the teacher wanted me to
do and say, not because I am so undisciplined, but because
I couldn’t bear a simulation/situation in which “the
technique” was put at first place while the other
fundamental elements of the relationship had to be
submitted to the protocol. In particular with EMDR you had
to follow, at least during the training, the eight steps
in a very rigid and restricting way. Said that, in
my clinical experience I found very useful to sometimes
introduce the ‘bilateral stimulations’ but in a way which
held no resemblance with the stereotyped descriptions of
the manuals. And I was very reassured about my (supposed)
lack of discipline and humility when I read, beyond the
official Shapiro’s manuals (in my opinion strongly
supporting the Shapiro’s economical empire) other more
creative and liberating writings of therapists like Paul
Wachtel who were able to free the bilateral stimulations
from the straitjacket of the STANDARDIZED EMDR. As Paul
wrote in his article ‘EMDR and Psychoanalysis’ : “…
strictly speaking, the work I will
describe here is not EMDR. As it is presently
defined, and presently practiced, EMDR is a highly
structured treatment with a very specific set of steps and
procedures. What I will describe is a way of working
that is inspired by EMDR, that draws upon some of the key
elements of EMDR, but it differs quite substantially from
the way EMDR is most typically practiced”.
Actually I think that
every timewe are with our
patients and not in the simulated situations of manuals
and training our work
differs quite
substantially from the way A CERTAIN TECHNIQUE is (
supposed to be) most typically
practiced”.
Therefore back to what Allan wrote,
maybe some therapists would benefit from learning and
working in accordance with manualized treatments but
others, with different temperaments and attitudes, had
better learn them and quickly forget them in order
to follow what the clinical situation really requests and
not remain stuck with the steps the different protocols
require.
Tyler Carpenter, 14 March 2006
Dear Tullio
and Luca,
The more I
listen to and think about the points I hear you both make,
the clearer it makes me think about what I share with you
both in terms of how I work. At the same time,
paradoxically, the harder I find it to understand why I
simultaneously find others' remarks about integrating
research findings and the value of manualized approaches
so compatible with my own thought and practice. Luca's
description of his experience of EMDR training was quite
similar to mine. However, I struggled to be more
disciplined in my adherence to the technique itself
primarily because I found it so enjoyable to have the
experience in that format myself (even if it isn't
critical to the therapeutic effect of the technique). The
remarks I made in my Psychotherapy Research book review of
Francine's "Paradigm" text on EMDR from other
perspectives, similarly appreciated the light chapters
like Paul's brought to an understanding of the EMDR
phenomenon. Luca's description of how he incorporates EMDR
concepts is quite similar to mine. And then I had a bit of
a flash: I assimilate and accomodate all techniques and
theories in a similar manner, whether they come from
manuals, empirical articles or more dialogic approaches or
wherever. Years ago I remember learning how so many modern
artists move from classical learning to modern expression.
I was subsequently less floored when reading about Miles
Davis development (I have taken up my trombone after 40
years absence from playing to retackle the golem of jazz
improvisation which discouraged me from developing my
already fine technique so long ago) to learn that he
rarely listened to jazz, but in fact he listened more
contemporary French composers and classical music. In fact
this catholic approach to enjoying assimilating other
styles and genres of music than one's own music is one
many musical performers adopt. I understand from a recent
tome on the development of the trombone that the
post-modern musician's approach to playing requires such
-an eclecticism in order to survive financially. Perhaps
the most unstructured approach I ever adapted to or
incorporated parts of was Robert Langs' Bipersonal Field
framework. When years ago I listened twice to a 12 hour
sequence of his tapes while driving across Iowa and
Kansas, I was alternately appalled and enthralled by the
somewhat paranoid, but extraordinarily sensitive approach
to the nature of the interrelated technique and
therapeutic relationship in his way of working. When I
tried out the concepts in practice I found the conceptual
framework was tremendously powerful. Some years back a
senior colleague suggested to me that I seemed to have a
way of thinking and working similar in style to Lacan.
Although I've since come to believe his remarks were more
a way of gently appealing to my narcissism and helping me
to extend my understanding by reading this great man's
work, it also alerted me to my tendency to incorporate
(maybe even ingest) and play with new concepts in such a
dramatic and reorganizing way at times as to make them my
own and helpful to my patients and comprehensible to my
colleagues in discussions. If this is the case, then it
isn't hard for me to see myself as quite open and
philosophically compatible with both empirical and
dialogic approaches as long as I can use them in a way
that I understand and is demonstrably useful to
those I seek to help.
George Stricker, 14 March 2006
In general,
I am not a fan of manualized treatments. However, rather
than "learn them and quickly forget them in order to
follow what the clinical situation really requests and not
to remain stuck with the steps the different protocols
require," as Luca suggests, wouldn't we be better off
learning them, adapting them, and drawing on them as
relevant in our clinical situations?
Luca Panseri , 14 March
2006
George,
When I say “quickly
forget them” I’m referring to a mental
attitude – the “negative capability” Hilde mentioned- that
can be cultivated only if we are willing to let go all our
(supposed) knowledge (included the steps of a protocol)
and be open to whatever happens in the clinical
situation.
Tullio Carere, 15 March
2006
George and Luca,
the two positions described by you go
beautifully hand in hand in the assimilative-accommodative
integration: George's assimilative, Luca's accommodative.
But you both clearly have both arrows in your quivers.
Allan Zuckoff, 16 March
2006
Dear Luca,
Many thanks for
your thoughtful and non-defensive response to my rather
pointed comment. Allow me to say, as an initial
disclaimer, that I feel much the same way about the
therapeutic empire-building evident in institutionalized
EMDR as you do. In the therapy community I feel at home
in, that of motivational interviewing (among whose
membership can be found several other members of SEPI),
there is a semi-directive therapeutic method with various
structured interventions adapted from it, all
well-described in books and manuals. But there is no
hierarchy and no for-profit accreditation process (indeed,
as yet, no official “certification” at all); training
materials are “open source;” and the developer of the
approach has publicly described how one manual he wrote
led to a failed controlled trial because it was “wrong for
the right reason”—precisely in having forced therapists to
be rigid in their performance.
That said, my main
response to your post is this: It is both more difficult,
and potentially more rewarding, for an experienced and
skillful therapist to learn a structured, manualized
therapy, than for a novice to do the same. More difficult,
because (ironically) it requires just that form of epoche
that has been described as the sine qua non of
process-oriented psychotherapy—but in this case, it is a
willingness to suspend preconceptions about what “good
therapy” is, long enough to enter and understand the world
of the novel treatment. More rewarding, because after the
initial, epoche-facilitated learning is done, the wisdom
of previous experience can be brought back into play,
allowing for the integration of what is valuable in the
new, into the richness of what was there before.
So I think that
what you have described is the natural process of an
experienced therapist’s genuine encounter with a novel
therapeutic techne, which is what George has also, I
think, been describing. And isn’t this what Paul Wachtel
described himself as doing before writing the seminal book
on psychotherapy integration that is as responsible as
anything for the existence of SEPI?
Allan Zuckoff , 16 March 2006
Tullio,
Gaslight, they say,
was ever-so-much-warmer than the electric lights we now
rely on. But gaslights were also comparatively
inefficient, and apt to explode—and refined electric light
turns out to be capable of a warm and mellow glow. But
what Luddites always fail to recognize is that new ways of
doing things can often incorporate that which remains
valuable from the old ways.
Although you seem
unwilling to understand this, well-written manuals provide
for the complexity and variability of “real” therapeutic
encounters. When I do “manualized” therapies, I am highly
attentive to process, empathy and its vicissitudes,
alliance and misalliance… In some cases, these factors are
central to the therapies as described in their manuals; in
others, they are less explicitly described than they
should be, but just as necessary (and their relative
presence or absence undoubtedly accounts for those famous
“therapist effects”). Yet the “procedures” I follow allow
me to accomplish more than I could by using only the
process-focused procedures you rely on.
And this is because
meaning is not “given” to others’ behavior, but inheres
for us within it; when others perceive our behavior, they
perceive that inherent meaning, from their own perspective
(with all that implies). Otherwise, it would be possible
to attribute any meaning to any given behavior, which of
course is absurd. Because the perspective that clients
bring to their encounters with us co-constitutes the
horizon against which our behavior appears, our “same”
behavior may be more or less therapeutic for different
clients, and we need (as a profession) to understand this
in ways which thus far have eluded us (as a profession),
and to learn how to tailor whatever procedures we engage
in more individually. But the procedures are what they
are, and your “process-oriented” approach is just as much
subject to these truths as are more “structured”
interventions. The thing to which
you arrogate the term “psychotherapy” is the form of
therapeutic encounter I love most. (I, too, have some of
the Luddite in me.) And, if my choice were determined
primarily by what I find most “comfortable” (to use your
word), it’s probably all I would do. But I’ve learned that
doing a semi-directive form of client-centered therapy
called “motivational interviewing” often allows me to help
addicted clients change their lives with remarkable
rapidity. And I’ve found that, by doing a structured,
experiential / cognitive-behavioral form of therapy with
clients with “complicated” (a/k/a traumatic) grief, I
could help them come to accept the death and reengage in a
meaningful life in months rather than years. And these
experiences made it clear to me that my comfort level had
to take a back seat to the well-being of those I
serve. Hilde Rapp, 16 March 2006
Dear Allan, Tullio,
George, Luca, Tyler and others on this thread, I greatly
appreciate the trouble everyone is taking to explain their
position with such care and good grace. I apologise
that some of my recent contributions have not been very
conversational but rather hasty bullet points…
I wonder
whether we are struggling with the distinctions between
capability, competence and excellence?
I am a member
of professional registration board and very similar
discussions have taken place there to those on this list
about how one should define what senior
practitioners do and how this could possibly be done
justice to in a formal portfolio based
assessment…
There are
other functions also, such as standardizing a
set of interventions for research purposes…), but it
seems to me that one important function of
manuals is to aid the cost and time effective
training of junior therapists in order to
equip them with the basic capability to practice safely
and effectively under supervision so that they may
with practice become competent independent
therapists. (I have a supervision menu which
systematically tests for certain competencies, on of
which is the capacity to work coherently, consistently and
creatively within the therapeutic model which informs
their practice, and which could be specified in a manual).
Manuals are
the distilled essence of what senior practitioners see as
the lineaments of competent professional practice, broken
down into units of competence, organized into
a protocol with accompanying guidance of how
to assemble these units flexibly into a treatment plan
which structures a sequence of therapeutic
actions designed to achieve certain
therapeutic goals safely and effectively.
When a senior
practitioner uses such a manual, one of two
things may happen ( to simplify hugely) .
The first is – if
the therapists is in tune with a protocol driven
approach- the manual will act as a prompt to bring all
their experience and expertise to bear on the clinical
situation. Then their performance will be- to all intents
and purposes- indistinguishable from that of a therapist
who practices without a manual- as was of course the case
for the therapist who wrote the manual in order to
capture his or her non manualised prior practice. What you
get is excellence. The manual does not and cannot capture
excellence- it is only capable of capturing competence and
it aims to do just that.
The second is
what happens when someone like Tullio, who is
committed to excellence, believes that in order to adhere
to the manual he must scale down his performance to be
merely competent, and he experiences this as a
painful loss of finesse, complexity and depth.
However- and Allan,
you have already made this point very eloquently-
excellence is excess, excellence is practice open to the
noumenal, unshorn of all the excess meanings that real
experience and depth of feeling, and the analysts among us
might say, the unconscious, and the analytical
psychologists might say, the archetypal and transpersonal
bring to our practice. This can
not be described or prescribed- by a manual, because it is
something that can only be lived ( we sometimes call this
the quality of the therapists presence- some people might
even think of the therapeutic encounter as the locus
in which the divine or transpersonal manifests
through an act of grace, and by definition, grace cannot
be bidden.)
Despite Tullio’s
fears, excellence is not pro-scribed by the use of a
manual: A manual is like a karate kata,
in that it constrains a sequence of
therapeutic moves. The performance of a yellow belt and
that of a black belt master practitioner contains the same
sequence of moves. However, while the yellow
belt is, through practice, developing her
basic capability to move towards
competence, the master is performing her moves
with the strength, discipline, presence of mind,
skill, fluidity, art, grace and focus
characteristic of excellence- and we can all tell the
difference… To change metaphor,
excellence is due to the personal
qualities of the actor ( this includes George’s
therapist factors), not due to the letters of the
script- however good.-
So, dear
Tullio, fear not to be shorn of excellence by submitting
to a certain discipline… Tyler Carpenter, 16 March 2006I wonder whether we
all, from novice to senior practitioner, work at the
confluence of capability, competence and excellence, Hilde
? However, what the senior clinician may experience more
frequently is what Mihaly Csikszentmihalyi calls flow and
that is both what happens when we're
fortunate and in part why we do what
we do.
Not long after I wrote my
last response I lay down to listen to Chet Baker's heart
breakingly beautiful CD "You Can't Go Home Again." On it
Chet was revealing how he had come back from his darkness
and his friend Paul Desmond was there to accompany him and
three months from his own death. The liner notes contain
the following 1938 quotation from a talk the author Thomas
Wolfe gave at Purdue five months
before his own death:
"I did not
know that for a man who wants to continue with the
creative life, to keep on growing and developing, this
cheerful idea of happy establishment, of continuing now as
one has started, is nothing but a delusion and a snare. I
did not know that if a man really has in him the desire
and the capacity to create, the power of further growth
and further development, there can be no such thing as an
easy road. I did not know that so far from having found
out about writing, I really found out almost nothing...I
had made a first and simple utterance; but did not know
that each succeeding one would not only be...more
difficult than the last, but would be completely
different, that with each new effort would come new
desperation, the new and the old, sense of having to begin
again at the
beginning all over
again; of being face to face again with the cold naked
facts of self and work; of realizing again that there is
no help anywhere save the help and strength that one can
find within himself."
This is a little dramatic in some
ways, but captures what I look for and find when I really
try on something new, whether from a manual or wherever,
and really look at it and feel what I could only look at
and feel in part before. When this happens with the
patient there is nothing better and we and the staff know
it. However, what I really see and feel more deeply is
just how much we all can see that we didn't see before and
how important it is that we not call it or try to
reproduce it in a way that can only obscure the subtlety
of the experience and it's irreproducible evanescence.
Tullio Carere, 16 March
2006
Dear Hilde and
all,
I remember one of my first
trainer analysts who used to say: "This is the theory and
this is the technique, but in the analytic hour forget all
about that. Just be there". She never used the expression
'freedom from memory and desire', but this is what she
meant. It is a basic principle of the philosophia
perennis, which one also finds in phenomenological epoché,
in za zen, and in many other disciplines. In your terms,
she wanted us novices to learn excellence in the first
place, not competence. So, to the other variations of the
basic dichotomy (manualized vs. non-manualized, theory
centered vs. dialogue centered, stereotyped vs. heuristic,
procedure oriented vs. process oriented) we could add this
one: excellence oriented vs competence oriented.
The process
(or dialogue, or excellence) oriented therapist follows a
line which I (today) would call of assimilative-
accommodative integration. In this line one can assimilate
virtually anything into one's home theory, even manualized
methods - but then, whether or not the assimilated
thing is originally manualized is irrelevant, because in
any case the manualization is lost in the process of
assimilation (see for instance what happened to EMDR when
assimilated by Paul, Luca, Tyler, and myself). The process
of assimilation is a heuristic, not an empiric affair. You
cannot be dialogue-centered and procedure-centered at the
same time. You cannot be the servant of two masters, you
have to choose. Either you choose to be silent inside, and
through this silence you open the space in which genuine
dialogue happens, or you have a mind full of algorithms. A
mindful mind is not a mind full of things.
What the
process oriented therapist (either senior or novice) aims
at fostering, is what Csikszentmihalyi calls flow, as
Tyler reminds us. In the flow all memory and desire, of
both patient and therapist, of course return. The
therapist's memory includes all theories and techniques
assimilated in years, but they turn up in the analyst's
mind in the same way as all other associative material. A
piece of a behavioral technique can be as relevant as a
scene of the picture I saw last night to the understanding
and the processing of the present material. And how do we
decide what is relevant in this very moment? The procedure
oriented therapist consults his/her mental diagnostic and
therapeutic manuals, trying to match the appropriate
procedure to the problem or need in question. The process
oriented tries to understand what the process requires in
this very moment, and to respond fittingly. In so doing
he/she does not draw on manuals but on common sense, i.e.
the noetic-dianoetic function (the dialectic of intuition
and reason) that is the basic competence of every human
being.
To
the development of this basic competence, the procedure
oriented therapist counterposes more specialized
competences. I do not object to this choice, provided that
one does not object to mine. This discussion has helped me
appreciate the protocol oriented therapy for the treatment
of special conditions or for the training of therapists
who are not interested in becoming process oriented or for
public services and third payers who are more
symptom-reduction sensitive. The two lines of
psychotherapy integration can coexist but still don't
meet, at least in my mind. You say, Hilde, that
"excellence is not pro-scribed by the use of a manual",
and compare manuals to a "karate kata, in that it
constrains a sequence of therapeutic moves". I
understand your example. In karate, as in many other
disciplines, technical competence is the basis, and
excellence develops, when it develops, on this basis. The
karateka must firstly be competent, and then possibly
excellent, in his/her art, and the same is true for the
protocol oriented therapist. Competence is not conflicting
with excellence, to the contrary: one has to be competent
in one's specific discipline, before becoming excellent.
Your example is well chosen: the aim of the karateka is to
win the fight, as the aim of the protocol oriented
therapist is to defeat a symptom. But dialogue is
different. The only thing you have to fight in dialogue is
your own ego and its epistemophilic drive. You don't fight
symptoms as a rule, because who knows, the patient could
need this symptom right now. The ego grows stronger when
it knows many things, many procedures. The only thing a
dialogue centered therapist wants to know, is that he or
she knows nothing.
Can the two lines of psychotherapy
integration be combined, as most of you maintain? Maybe
they can, although I still cannot see how. Yet, for the
time being, it seems to me far more important to
distinguish them than to combine them. You know what
happens when one melds a strong thing with a weak one,
don’t' you?
Hilde Rapp, 16 March 2006
Dearest Tullio,
I am so
touched by your struggle! As you know my homeland is
dialogue and the dialogic imagination. I can see that
psychotherapy education (I prefer this to training) can
make a native preference and sensibility toward dialogic
and relational ways of engaging with others more refined.
We can with practice and reflection become more
competent at dialogic forms of engagement.
The
distinction between competence and excellence is akin to
that between techne- craftswomanship and arts- artistic
fluency. Many people can become good craftspeople
and make very serviceable furniture and bronze castings
exhibiting good workmanship, pleasing design and fitness
for purpose. In a busy city we need many tables and chairs
and a few good sculptures too, and hence many
craftsmen and women good at making them. As you can see my
metaphor predates the age of the technical
reproducibility of the work of art that Walter Benjamin
talks about so brilliantly. In the spirit of this
metaphor, I am sure you would grant me that many of these
highly accomplished craftsmen or women nonetheless
never achieve the flair and elegance and beauty that would
take our breath away so that we say that this
is a truly excellent chair of Bauhaus quality- in fact,
really a work of art or that this pleasing figurine
in our garden has the breath of Rodin upon it.
There maybe schools
of carpentry that only ever aim for training craftsmen,
but many such schools would hope to provide an education
that will bring out and help to flourish any artistic
talent their students might have- ah! here at last
we have our very own Thomas Chippendale…
So, give a manual
for making a chair to a Mies van der Rohe, and he
will make you a work of art. Apprentice someone to
a Michelangelo and he might still never become a
true master, and he might not even become a good craftsman
because the necessary steps in the process were always
implied but never spelt out in a way that they could be
followed, repeated and practiced…. and you would not buy
his statue for your garden.
Every
metaphor only carries us so far, and every transference
might want to carry us in the opposite direction…
Like you I have
worked hands on in the health service and I have seen many
services at primary, secondary and tertiary care level in
a role where I have been responsible for ensuring
that they actually made a difference to peoples wellbeing.
I have
unfortunately seen services which spent
a lot of money on serving a very small number of people
without being able to show what results they had
achieved in moving their patients from the clinical
spectrum to the non clinical spectrum because they used no
outcome measures at all.
In many
cases this money can be better spent by offering much less
ambitious , more symptom oriented therapy to a much
lager number of people moldering on waiting lists
over twelve or twenty four sessions , by using
treatments such which have been shown by research to
improve the lot of particular client populations.
This approach may be manualised, and if so, it is even
more likely that a service can actually track and monitor
outcomes perhaps even with the option of linking
outcomes to therapist behaviours. Also people can be
trained to use such approaches much less
expensively. Many people will get better by working with a
good craftsperson- because a craftsperson is not just a
professional, they are –as you say good human beings,
sensitive, full of good will and many other
things which normally come out as ‘common factors’.
They are common to human beings, they are not common to
people because they have been put there by a training-
they were already there. The training helps to refine and
direct our way of being with people so our learnt
repertoire of interventions can be brought to bear.
There are
many people who cannot so helped and who do need a truly
dialogic engagement in order to reach into their
difficulties. If money is saved by helping people who can
and will improve with procedural interventions, then
more money is available for those who need an artist in
order to get back on their feet, or to get onto their feet
for the first time. A four tier service model would
accommodate such an approach to meeting client needs-
where treatments become more complex and lengthy and
resource intensive as the client’s difficulties
become more complex, severe, chronic and
pervasive…
I would never argue
that we should only have procedural approaches, manualised
or not, or only have dialogic approaches, or that all
dialogic approaches should teach procedures and vice
versa. I am only arguing that there is need to have
space and respect for understanding why we may
choose one approach or another, and when and where
one choice may be more appropriate than
another- and these reasons are usually justified on
pragmatic grounds, rather than on theoretical ones.
Therefore my understanding of integration
is at the meta framework level that I have
briefly mentioned and which I will say more about in
Florence. It is heuristic that allows us to make clinical
decisions on the basis of client need. Theoretical
allegiance can alto readily lead to a supply led system,
which as Mike Basseches puts it, may do
serious ‘violence to the clients meaning system’.
I can imagine
a world in which all therapists are excellent and all
governments have the money to fund only excellent
therapies- and if it ever comes to pass I will move
there tomorrow.
I live in a world
where a cash strapped service competes with housing and
education to meet people’s needs, where therapy trainings
are lengthy and cost at least 30 000 dollars and
where people from ethnic minorities have little
choice but to enter trainings which will equip them
in a shorter time and at a lower cost with the essential
knowledge and skills (competencies) to help
members of their community who are currently poorly served
by white middle aged therapists who are
informed by ethnocentric theories. So my votes goes
to them.
However!!! I
will at the same time campaign energetically for us to
walk on the hard road to that other world where dialogue
and inspiration flourish and serve to empower
people to lead full and creative lives. I hope and
wish that we can shorten the gap between what is and what
might be by working together internationally as we are
right now, thanks to you, Tullio.
Mike Basseches, 16
March 2006
HelloTullio, Hilde,
et al.
Well, reading
Tullio's post that arrived on this side of the atlantic
this morning and finding myself heartily agreeing!,
I was already again regretting that I haven't
been able to follow every word of this wonderful dialogue,
but feeling drawn in enough to hit the reply
button, hoping that over time today I could
figure out if there was anything I wanted
to say besides, "right on, Tullio.". Then reading
Hilde's response, what I wanted to say became clearer,
only to discover as I read further on that she had already
included me, by citing me. (Thank you, Hilde!)
I think that I basically agree with Hilde that the
contributions of all therapists to their clients' well
being, across all forms of training and degrees of
expertise, should be very much appreciated, and
fostered. Nevertheless, the first point she makes
below, as well as the later sentence in which she cites
me, lead me to want to add this little caveat
or clarification to Hilde's idea of a
four-tier service model. In recognition of the harm
done to clients when Tullio's "procedure-oriented
therapist" fails to recognize that the procedure isn't
working for a particular client (or worse, recognizes it
and "blames" the client for not responding appropriately
to a treatment, empirically-validated or otherwise), it
seems important that all
therapists' education aim at the epistemological
sophistication needed to locate appropriately whatever
they "know" about any procedures that they use (and
whatever they do in whatever tier they are working) within
the sort of broader "psychotherapy integration" universe
that Tullio, as well as others in SEPI, have been working
so hard to describe.
Granting Tullio the
"poetic license" to overstate it and oversimplify it a bit
in the interest of dramatic expression when he says, "The
only thing you have to
fight in dialogue is your own ego and its epistemophilic
drive. You don't fight symptoms as a rule, because who
knows, the patient could need this symptom right now. The
ego grows stronger when it knows many things, many
procedures. The only thing a dialogue
centered therapist wants to know, is that he or she knows
nothing.",
I would agree with the following
claim: Given a choice between a psychotherapy
integration that rests on the foundation of recognition of
what we don't know (as well as what we tentatively do
know) and of the processes by which we together with our
clients discover more, and a psychotherapy
integration that rests on holding tight to what we do
know and assimilating as much as possible to it, the
former does seem like the sounder choice.
Hilde Rapp, 16
March 2006
Dear Mike,
dear all
Thanks for
the caveat- well taken! Meta- frame works rely on
meta-cognition- and meta –cognition is thinking about
thinking- and thinking about thinking always leads to
questions, not answers. I am quoting myself to say that a
good therapist needs to know when to ask good questions
and when to wait for the client to ask them him or
herself! ( procedures can be very helpful at generating
good questions…they may be less good at dealing with
pregnant silences…)
Tullio Carere, 19 March
2006
Dear Mike, Hilde
and all,
Thank you for supporting
me in the struggle for the priority of unknowing over
knowing, and for forgiving my "poetic license" in
overstating my case. You most fittingly draw attention to
the harm done to clients when the
diagnose-and-procedure-oriented therapist "fails to recognize that the procedure
isn't working for a particular client (or worse,
recognizes it and 'blames' the client for not responding
appropriately to a treatment, empirically-validated or
otherwise)". The theoretical abuse, as you properly
call it, is the risk inherent in any theory-driven
therapist unable to neutralize their theoretic allegiance
and to dwell in a theory-free space. To minimize this
risk, you (and I) deem it important that "all therapists' education aim at the
epistemological sophistication needed to locate
appropriately whatever they 'know' about any procedures
that they use (and whatever they do in whatever tier they
are working) within the sort of broader 'psychotherapy
integration' universe" that I have tried hard to
describe. This implies that the sort of "psychotherapeutic
craftsmanship" currently happening and empathically
described by Hilde should not be encouraged, unless it is
preceded by a proper psychotherapeutic education.
This is what
Allan too seems to maintain, when he suggests that
protocol-driven procedures should be used by therapists
who have "critical common-factors
therapeutic skills including capacity for empathy,
alliance-building, flexibility". They can therefore
use a protocol-driven procedure with enough detachment as
to able to recognize when it does not work for a
particular patient. Consequently, they would modify it to
adapt it to the present situation if possible, or would
abandon it at all. In this case the danger of theoretical
abuse would be shunned, and a comparison would be
acceptable between a manualized and a non-manualized
treatment. But this comparison will not be easy, until
non-manualized approaches will have equal possibility of
being funded than the manualized, as Paul points out.
Anyway, in the meta-analysis of controlled studies of
motivational interviewing (MI) that Allan fairly
quotes the overall effect size for manualized MI is 0.35;
for non-manualized MI, 0.65. To say the least, so far we
don't have much evidence showing the advantage of
manualized over non manualized therapies.
I would
emphasize the following points:
1. We should
beware the danger of scientism and technicism currently
plaguing our field. The basic education of all
psychotherapists should be informed by a dialogical
attitude based on the development of the capacity of deep
listening and of relating in the basic modes corresponding
to the critical relational common factors.
2.
On this base every school, group
and individual therapist could assimilate all sorts of
theories and techniques, as a function of preferences,
chances, and fields of application. But this assimilation
could happen in two radically different ways: one is
empirical, the other is heuristic, corresponding
respectively to the procedure oriented, and the process
oriented approach.
3. The
procedure oriented approach is theory driven. The
procedure must be manualized in order to prove its
efficacy in the treatment of a specific disorder, and the
protocol must be applied faithfully enough to ensure its
empirical validity.
4. The process
oriented therapists remain true to their basic dialogical
attitude. They have of course theories and techniques, but
these are just a component of the therapist's person that
is at stake in the dialogue like any character trait, no
more and no less: surely they are not the principles
guiding the therapy. To the contrary, they are bracketed
all the time in order not to saturate the space of the
dialogue.
5. In the
research, the procedure and the process oriented
approaches should have equal possibilities of being
funded. In the evaluation of the results, symptom
reduction should not be the main criterion. Relationship
pattern or character change should be at least equally
rated.
This
is what is clearer to me now, thanks to this wonderful
discussion, and what I am going to say in my presentation
in Florence, save further corrections due to your
feed-backs in the next days.
Tyler Carpenter, 19 March 2006
Tullio, at the risk of being
misperceived, perhaps, the only way I can describe your
synthesis is to call it lovely! Although I'm not
sure that it is possible, perhaps you might try to apply
the same lyricism (what George B. Murray referred to in
part as "limbic music") and poetics in/to your
description of the more instrumental
and scientific approaches, as you do with the dialogic. I
keep thinking that if I didn't know the practical
importance of your theoretical position, I would be left
feeling that I was a part of the undesirable "other" if I
identified my self professionally with the characteristics
you describe as belonging to the theory driven therapist.
I suspect that the very experienced therapist is likely to
appreciate, if not savour your analysis (sorry or not for
the
choice of descriptor).
However, the less experienced or more theory identified
therapist may not be able get around the subtle, but
negative emotional valence attached to what
epistemologically is also just a position and is not
without its negative, but less elaborated effects on the
patient.
Perhaps there's no
getting around the conflict inherent in such discussions.
It sometimes seems to me that to attempt to divest a
statement of all its potential for negativity and
conflict, is to forget what we understand about the nature
of the process we are attempting to treat and suck the
essential
meaning from the life we
and others are all a part of.
George Stricker, 19 March
2006
I don't think I disagree with any of
Tullio's broader conclusions, and clearly am not a
manual-driven therapist. You also, quite correctly, in my
view, call attention to "the harm done to clients when the
diagnose-and-procedure-oriented therapist fails to
recognize that the procedure isn't working for a
particular client (or worse, recognizes it and 'blames'
the client for not responding appropriately to a
treatment, empirically-validated or
otherwise)”. However, in putting together your
presentation, which most of us will not have the benefit
of hearing, you might want to consider what happens when
the process oriented therapist fails to recognize that the
procedure isn't working for a particular client. In
understanding the fallibility of all of us, it is
important not to close off any tools, procedural or
process, and to be open to whatever we may learn about any
of the approaches.; It also means we have to be able to
fund the full panoply of approaches, something that we are
not doing at the present time.
Mike Basseches, 19 March 2006
So Tullio, if
you're asking for any more "corrective thoughts" before
presenting Florence, I have thoughts about how I would
respond to Tyler's concern. If I read you right,
Tyler, you are concerned that there is an, however small,
"demonizing" element to Tullio's position. I think
what Hilde and I have both tried to communicate are the
following points, which are efforts to counteract such
"demonization": 1. Every single therapist has the
potential to contribute valuable resources to clients'
developmental struggles, and to the effort in therapy to
create new and valuable personal knowledge, and this is
something that we should all celebrate, and incorporate
into our advocacy for psychotherapy. 2. Every component of
psychotherapy training, whether it takes the form of a new
theoretical idea, a new procedure or technique, or a new
research finding about psychotherapy -- manualized or not,
or a new proposed integrative synthesis, has the potential
to augment the resources that any given therapist has to
offer. This too we should all celebrate, and
incorporate into our advocacy for
psychotherapy training and research. The engagement
in psychotherapy practice, training, theorizing, and
research, on anyone's part absolutely should not be
demonized. But the dialogical common ground on which
I, and I believe Tullio, would like us all to meet, is the
recognition that the arena in which any psychotherapeutic
knowledge or ideas, whatever their source, must ultimately
be "validated", is in the dialogue/relationship between
therapist and client in which further new knowledge can be
co-constructed, and the impact of that new knowledge on
the lives that the client and therapist live beyond that
relationship. If some would exclude others from even
entering that arena, or would create funding mechanisms
and principles such that many are de facto excluded
because they can't afford the ticket of admission, this is
indeed a problem and the one that Tullio may be
addressing. I think that both the humility reflected
in recognizing the need to subject any psychotherapy
practice, whether procedure or process-oriented to this
acknowledgment of fallibility and process of validation,
is what George has appealed for in his recent post, while
also arguing for non-discrimination and maximizing
access. Do I get you right, George?
If there is a negative side to
this epistemological position, I am probably somewhat
blinded to it, and so Tyler, I would certainly appreciate
your clarifying what you think it is.
Tullio, I appreciate your bringing all
of us along, even if we can't be in Florence
physically. If I find myself seeing any of the
beautiful sights of Florence in my dreams, I'll understand
why. Best wishes, and please let us know how the
presentation goes.
Tyler Carpenter, 19 March
2006
As the saying goes, Mike, "The devil
is in the details." Depending on how a position is framed,
there is a "negative" side to every position which is the
point I was trying to make in quoting Lao Tzu. However, it
is my understanding that ancient emperors and periods of
Chinese culture supported Buddhism, Confucianism, and
Taoism precisely because of what each, separately and in
concert, brought to the lives of the people and the
culture. A forensic colleague recently pointed out when
describing a delightful graduate school admissions
interview he conducted with Taiwanese candidate, when
asked if the candidate had a particular philosophical
preference, he (candidate) said, "When we want to do
something correctly we quote Confucius. When we want to
take a nap we quote Lao Tzu." Sometimes one's a samurai
and at other times a ronin. I found both yours and Hilde's
and George's and Allen's and Paul's points all quite
helpful and thoughtful in their ways, Mike.
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