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 time we 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 2006
I 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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