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Psychotherapy Integration:
A Postmodern Critique
Jeremy D. Safran and Stanley B. Messer
Editor's note.
Pluralism is "an antidote to parochialism and the attitude
that absolute certainty is obtainable", and contextualism is
"the hypothesis that an event cannot be studied as an isolated element,
but only within its setting," we are reminded by Safran and Messer.
Pluralism and contextualism are two of the main characteristics of
the postmodern attitude, which comes up against the pretences of absolute
and neutral knowledge that are often considered to be the hallmark
of modernity. Whether these pretences belong to modernity as such--as
an inevitable aftermath of the Enlightenment--or they are better understood
as symptoms of the unachievement of the Enlightenment project, as
some maintain, it is a controversial matter. An injection of pluralism
and contextualism is in any case a remedy for those pretences. As
for all medicines, on the other hand, its beneficial effect is dose
dependent. While a proper dose of pluralism and contextualism is surely
beneficial, an excessive dose could produce some side effects. One
of these is certainly relativism, which is a risk for postmodernism
as the uncritical objectivation of knowledge was for modernity. The
Authors are well aware of such risk, and point to dialogue
as to an antidote to it: "The reason that dialogue is critical is
because it provides a means of moving beyond our preconceptions toward
a better understanding of the things themselves". To dialogue means
to communicate on the common ground of the logos, that is on
the ground of the universal reason, and it is made possible by a movement
beyond all preconceptions. But what remains of pluralism and contextualism,
once our preconceptions are removed? Aren't they the very substance
of our preconceptions? And wasn't a postmodern tenet that there is
nothing like "the things themselves", as there are only "things within
their settings"? This contradiction is only apparent, if we consider
that postmodernism is not, and cannot be, an ideology to replace modernism
(it would be self-contradictory, if it had this pretence). Postmodernism,
at its best, is a healthy reaction against rationalism, i.e. the tyranny
of reason. As such, it is not a substitute for the logos, but
a correction for its misuse and abuse. As there is no choice between
one and many, by the same token there is no choice between modernity
and postmodernism. What is needed, in both cases, is a dialogical-dialectical
perspective, as Safran and Messer suggest throughout their article.
Psychotherapy
Integration: A Postmodern Critique
Abstract
This article critiques major trends in the
psychotherapy integration movement from the postmodern perspectives
of contextualism and pluralism. A contextualist position asserts that
psychotherapeutic concepts and interventions can be understood only
within the linguistic, theoretical, and ideological frameworks in
which they are embedded. Therefore, they take on new meanings when
extracted from their original context and are incorporated into an
eclectic therapy. Pluralism holds that there is no single theoretical,
epistemological or methodological approach that is preeminent and
no one, correct integrative system towards which the field of psychotherapy
is evolving. In light of this critique, we argue that the goal of
the integration movement should be to maintain an ongoing dialogue
among proponents of different theories and world views thereby allowing
for the clarification of differences as well as the judicious integration
of alternative perspectives and techniques. The article also spells
out the implications of contextualism and pluralism for psychotherapy
theory, practice, and research.
Key words:
psychotherapy integration, postmodernism, contextualism, pluralism.
Reprinted from: Clinical Psychology: Science and Practice 1997,
4, 140-152
The last two decades have witnessed the beginning of an
important shift away from the prevailing climate of factionalism and
parochialism among the psychotherapies towards one of dialogue and
rapprochement (Arkowitz, 1992; Bergin & Garfield, 1994; Norcross
& Goldfried, 1992; Stricker & Gold, 1993). Integrative links
have been forged, for example, among psychodynamic, behavioral, and
family system therapies (e.g., Wachtel & McKinney, 1992), and
among experiential, cognitive, and interpersonal approaches (e.g.,
Safran & Segal, 1990). Commonalties across the different therapies
have been distilled into single therapies (e.g., Garfield, 1992; Prochaska,
1995) and techniques from several sources have been employed eclectically
in connection with the differing needs of individual clients (Beutler
& Hodgson, 1993; Lazarus, 1992). A poll which surveyed clinical
psychologists, marriage and family therapists, psychiatrists, and
social workers has documented that from 59% to 72% endorse eclecticism
as their preferred approach (Jensen, Bergin, & Greaves, 1990).
In this article we adopt a postmodern perspective to critique common
approaches to psychotherapy integration and to highlight the more
radical implications of the integration movement for shaping our attitudes
towards psychotherapy. A recurring theme in postmodern discourse,
deriving originally from Hegel (1910), is that self-identity emerges
only through the construction of "the other". The unfortunate effect
of this construction is that "the self" always gets defined in contrast
to "the other", who is thereby deprived of genuine standing. This
functions to validate and maintain the privilege of the self or of
the dominant group. Foucault (1967), for example, argues that during
the 18th century the insane (the "irrational") were placed in the
category of "the other" as part of the process of protecting and enshrining
the rationalistic values of the enlightenment. An important function
of postmodern critique is to challenge constructions of reality which
have the effect of marginalizing "the other".
One way to view the recent trend towards psychotherapy integration
is as a response to confrontation with "the other". In the conventional
discourse that has taken place among therapeutic traditions, each
approach has defined itself in contrast to the other. For example,
psychoanalysis is defined in contrast to behavior therapy by its emphasis
on the unconscious, and behavior therapy is defined in contrast to
psychoanalytic therapy by its emphasis on social influence. As in
the case of racial, ethnic or cultural differences, perceived positive
qualities of one's own group take on ritualistic significance whereas
other traditions are assigned a negative, caricatured quality. The
other is thus appropriated and used to define and enshrine the values
of the self (Sampson, 1993).
From a postmodern perspective, one of the most important functions
that the psychotherapy integration movement can serve is to help theorists
and practitioners move beyond the attitude of superiority, contempt,
and aversion which frequently arises from the confrontation of adjoining
therapeutic "cultures" towards a sense of surprise and eagerness to
learn, which is also a natural human response to difference (Feyerabend,
1987). One can compare the task of the psychotherapy integrationist
with that of the cultural anthropologist. Shweder (1991) refers to
the "astonishment of anthropology" in describing the core value which
orients the cultural anthropologist's stance:
Astonishment and the assortment of feelings that it brings with
it -- surprise, curiosity, excitement, enthusiasm, sympathy --are
probably the affects most distinctive of the anthropological response
to the difference and strangeness of "others." Anthropologists
encounter witchcraft trials, suttee, ancestral spirit attack,
fire walking, body mutilation, the dream time, and how do they
react? With astonishment. While others respond with horror, outrage,
condescension, or lack of interest, the anthropologists flip into
their world-revising mode. (p.1)
Such a consciously inculcated stance of astonishment is one of the
most valuable attitudes that can emerge from the psychotherapy integration
movement. To the extent that confronting alternate therapeutic paradigms
and techniques flips us into a "world-revising mode," versus the more
common stance of outrage and condescension, there is the possibility
of its leading to a dialogue which can truly deepen our understanding
of the human change process. The importance of dialogue of this type
is a recurring theme throughout the article and later we will explore
the central role that it plays in the scientific enterprise.
In the following, we critically examine the three most frequently
employed strategies for psychotherapy integration--technical eclecticism,
common factors, and theoretical
integration--in light of two defining characteristics of the postmodern
attitude: contextualism and pluralism. We also explore the obstacles
to integration that emerge at metatheoretical and epistemological
levels of discourse. The article concludes with the implications of
contextualism and pluralism for psychotherapy theory, practice, and
research.
Contextualism is the hypothesis that an event cannot be studied
as an isolated element, but only within its setting. Every event is
said to have quality and texture. Quality is the total meaning of
the phenomenon, and texture refers to the parts that make it up (Pepper,
1942). Quality entails a fusion of the textural details, e.g., "Lemon,
sugar, and water are the details of the taste, but the quality of
lemonade is such a persistent fusion of these that it is very difficult
to analyze out its components" (Pepper, 1942, p.243, after William
James). The postmodern notion that there is more than one correct
theory or perspective by which to view any phenomenon is known as
pluralism. It is an antidote to parochialism and the attitude
that absolute certainty is attainable. Seeing how other theories get
a grip on the world can lead to enhanced understanding and improvement
of the theoretical ground on which one stands (Nozick, 1981). While
contextualism notes that context often determines which of many possible
interpretations or meanings we give to an event, pluralism acknowledges
that there are multiple perceptions of truth, each one influenced
by the context out of which the perceiver arises in making his or
her judgments.
Technical Eclecticism
There has been discussion in the psychotherapy integration literature
as to whether integrative efforts should have a more applied or a
more theoretical emphasis (Garfield, 1994). Technical eclecticism
holds that theoretical integration involves fusing theories that are
irreconcilable, and that techniques should be combined pragmatically
on the basis of observed or presumed clinical efficacy ( Lazarus,
1996; Lazarus, Beutler, & Norcross, 1992). Lazarus’s multimodal
therapy is a good example of this approach. Techniques from gestalt,
cognitive, behavioral, psychodynamic, and family systems therapy all
may be applied in one individual's therapy.
One of the problems with this form of eclecticism is that it often
proceeds as if a therapeutic technique is a disembodied procedure
that can be readily transported from one context to another, much
like a medical technique, without consideration of its new psychotherapeutic
context ( Lazarus & Messer, 1991). The problem can be illustrated
by reference to the hermeneutic circle which stresses the contextual
nature of knowledge (Messer, Sass, & Woolfolk, 1988). Within this
view, a fact can be evaluated only in relation to the larger structure
of theory or argument of which it is a part, even while the larger
structure is dependent on its individual parts. Thus a therapeutic
procedure such as an interpretation or empathic response does not
stand on its own, independent of the framework of meaning created
by the entire therapeutic system.
This part-whole interdependence can be illustrated in various ways.
For example, a client whose treatment has been primarily cognitive-behavioral
may experience a therapist's shift to empathic/reflective responding
as a withholding of needed psychological expertise. Conversely, a
client whose treatment has been client-centered or psychoanalytic
may experience a shift to cognitive-behavioral interventions as controlling.
Although such interventions have the potential to be effective, their
meaning and impact should be explored in their new context. (e.g.,
see Frank, 1993, Messer, 1992).
In a second type of technical eclecticism, different therapies or
techniques are prescribed as optimal for different kinds of problems
or clients, rather than combined in one client's treatment. This is
known as prescriptive matching (Beutler & Clarkin, 1990; Beutler
& Harwood, 1995), differential therapeutics (Frances, Clarkin,
& Perry, 1984), or selective eclecticism (Messer, 1992). In asking
the question: "Which therapy is best for which type of client?", selective
eclecticism is a movement towards greater contextualization of therapy.
The prescriptive matching approach, however, ignores the fact that
two clients with the same diagnosis often have very different case
formulations (Collins & Messer, 1991; Persons, 1991). Moreover,
clients change both within one session and over the course of therapy.
This requires the skilled clinician to constantly modify interventions
in a context-sensitive fashion in attunement with a changing process
diagnosis, rather than applying a therapy module in response to a
static diagnosis or formulation (Rice & Greenberg, 1984; Safran,
Greenberg, & Rice, 1992). The failure to conduct psychotherapy
research in a sufficiently context-sensitive manner is probably one
of the factors underlying the difficulty demonstrating a consistent
pattern of therapist by client interactions (Beutler, 1991; Omer &
Dar, 1992). It is thus important for psychotherapy researchers to
conceptualize relevant variables in more process oriented, phase specific
terms that take ongoing context into account.
Common Change Principles as Integration
A second form of psychotherapy integration consists of the discernment
of common principles of change across different therapies (e.g., Frank
& Frank, 1991; Goldfried, 1980; Weinberger, 1995). For example,
a common principle in many forms of psychotherapy consists of helping
clients to become aware of and challenge their self-criticism. A closer
look at the ways in which this is accomplished in different therapies,
however, reveals important distinctions. In the scientific and rationalistic
spirit of cognitive therapy, clients are encouraged to challenge self-criticism
by treating their negative thoughts as hypotheses to be tested through
examining relevant evidence, or by considering alternative perspectives.
In gestalt therapy, by contrast, self-criticism is challenged by means
of eliciting an emotional experience through what is known as "the
empty chair" exercise. In this approach, clients' self-criticism is
expressed while sitting in one chair, and then confronted by their
emotional reaction to it while sitting in a second chair.
Although both of these techniques share the common principle of
"challenging self-criticism," important differences emerge when we
take into account the theoretical context in which interventions are
employed (Goldfried & Safran, 1986). The hypothesis-testing intervention
in cognitive therapy takes place within a theoretical framework which
views self-criticism as maladaptive thinking to be recognized, controlled,
and eliminated (Messer & Winokur, 1984). It is embedded in a modernist
world view, which values rationality, objectivity, and pragmatism
(Woolfolk & Richardson, 1984). Gestalt therapy, by contrast, regards
self-criticism as an aspect of the self which must be recognized and
then integrated with other parts of the self. In this therapy, the
values of emotional experiencing, subjectivity, and the complexity
of personality are paramount.
Since different therapies convey different over arching values or
messages (Beutler, Crago & Arizmendi, 1986; Kelly & Strupp,
1992), any intervention must be understood as part of a general process
through which such values are transmitted to the client. In the attempt
to extract common principles one can lose sight of important features
of the overall therapeutic system and the process through which it
works. As Wittgenstein (1953) once remarked, it is a mistake to try
to get to the essence of an artichoke by divesting it of its leaves.
We are not arguing that there is never any value to extracting common
principles. The utility of the specific common principle that is articulated,
however, depends upon the function that it serves in the phase of
dialogue between systems of therapy. In early stages of integration,
the articulation of common principles can play an important role in
facilitating dialogue where none previously existed. In this way it
can help to reduce the sense of "otherness". As the dialogue progresses,
however, it becomes more critical to explore similarities and
differences between orientations from a more nuanced perspective.
Anthropologists refer to this type of contextualized exploration as
"thick description" (Geertz, 1973). Thick description provides a corrective
to older forms of anthropological investigation which are more likely
to assimilate aspects of new cultures into existing knowledge structures
(Schwartz, White & Lutz, 1992). Geertz has argued that it is only
by understanding each culture in its uniqueness that we can learn
something new about the human condition. Similarly, the exploration
of other therapeutic systems in a refined, contextualized fashion
can lead to new understanding of both other systems and our own.
Thus differences among therapies in their higher level theoretical
constructs should not be ignored. Theories have a "trickle down" effect
on clinical practice. To return to our earlier example, challenging
self-criticism may convey a different message in the approach of a
therapist who subscribes to a theory that self-critical thoughts are
distortions to be eliminated, than it will in the approach of a therapist
who views them as reflecting a part of the self containing the seeds
of important strengths.
Theoretical Integration
In this form of integration, different theories are combined in
the attempt to produce a superior, over arching conceptual framework.
Wachtel's (1977) joining of psychoanalytic and behavioral theories
within an interpersonal psychodynamic framework, and Safran and Segal's
(1990) wedding of cognitive, experiential, and interpersonal approaches
within a single theory of therapy are good examples of this genre.
Such super ordinate integrative theories are said to lead to new forms
of therapy that capitalize on the strengths of each of its elements.
While the integration of pure form theories into one that is super
ordinate may bring certain advantages, the integrative theory could
lose some of the practical wisdom that has evolved over time in its
component therapeutic systems. In the same sense that interventions
cannot be understood outside the context of the theory in which they
are embedded, a theory of therapy cannot be fully comprehended without
reference to the details of its clinical implementation. As Geertz
(1983) suggests, in order to truly understand a culture there must
be "a continuous dialectical tacking between the most local of local
details and the most global of global structures in such a way as
to bring them into simultaneous view" (p.69). Similarly, a proper
appreciation of a therapeutic approach requires a tacking back and
forth between theory and the specifics of its implementation.
Organicism Versus Pluralism
There are other potential problems with theoretical integration,
to which a postmodern outlook alerts us. The task is sometimes approached
as if there were one correct integration waiting in the wings to be
discovered. Labeled "organicist" by the philosopher Stephen Pepper
(1942), this perspective (or "world hypothesis" as he calls it) presumes
that by organizing data at a higher level, the appearance of conflict
between ideas or findings is resolved by their incorporation into
an organic whole. Organicism posits that in the world we encounter
fragments of experience -- such as the observations of a school of
therapy. These appear with certain contradictions, gaps, or opposition
from other fragments of experience -- such as the observations of
other theories of therapy. The various fragments have a tendency to
be resolved by incorporation into an organic whole that, all the while,
was implicit in the fragments and that transcends them. In this view,
progress in theoretical integration is achieved by including more
and more of the fragments into a single, integrated, and unified whole.
There is an alternative view to organicism, namely that psychology,
by its very nature, is pluralistic: "Paradigms, theories, models (or
whatever one's label for conceptual ordering devices) can never prove
preemptive or preclusive of alternate organizations" (Koch, 1981,
p. 268). The pluralistic perspective holds that all theories are necessarily
limited and that the best way of approaching the truth is through
the ongoing confrontation of multiple, competing theories with data
and with each other.
Integration as Translation
Theoretical integration typically involves some element of reconceptualization
or translation from one framework into another. For example, in an
attempt to place the insights of psychoanalytic theory on a firmer
scientific footing, Dollard and Miller (1950) translated psychoanalytic
concepts into learning theory. Contemporary examples include drawing
on concepts from cognitive psychology to refine psychoanalytic theory,
such as efforts to account for the phenomenon of transference in terms
of schema theory (Safran, & Segal, 1990; Singer & Singer,
1992; Westen, 1988), and attempts to reformulate the psychoanalytic
theory of the unconscious by means of cognitive theory (Erdelyi, 1985).
Within a contextualist view, however, language and theory are inextricably
intertwined, which forces us to consider carefully what has been added
by the translation. Psychological meanings only make sense by virtue
of their interrelations to other terms within their conceptual setting.
Thus, for example, while attempts to translate a concept from one
theory into the terms of another may result in ease of empirical testability,
some of the concept's richness and subtlety could be lost.
Translation can also lead to the reductionistic fallacy which holds
that theory A (regarded as nonscientific) is more adequately explained
in terms of theory B (regarded as scientific). For example, it is
a mistake to assume, a priori, that the principles of
Chinese medicine can be better explained in terms of the principles
of Western medicine. As Sampson (1993) argues:
To examine a culture's own system of understanding requires
us to become familiar with the culture in its terms,
rather our own. This requires a dialogic rather than a monologic
approach. We must carry on a dialogue with the other culture.
In this dialogue our framework and theirs meet. Out of that
meeting a newly cast understanding of both them and us is
likely to emerge. (p. 185)
Metatheoretical Integration
In comparing the visions of reality contained within psychoanalytic,
behavioral, and humanistic therapies, Messer and Winokur (1984) have
illustrated the difficulties of integration at the metatheoretical
level. They argued that psychoanalytic therapy is guided primarily
by a tragic view of reality in which people are subject to forces
not of their knowing and which can be only partially ameliorated.
Behavior therapy, by contrast, falls more within the comic vision,
where conflicts are viewed as external and more readily resolvable.
Empirical findings on the process of these two therapies are consistent
with this description (Goldfried, 1991). The humanistic therapies,
by contrast, are characterized by the romantic vision which prizes
individuality, spontaneity, and unlimited possibilities in life.
Fundamental differences in world view are not readily integrated
because they are mutually exclusive in many respects and are typically
held as unquestionable presuppositions. Nor can they be resolved by
reference to the data. What Kuhn (1970) has said about the incommensurability
of different paradigms applies here: there is no set of rules to tell
us how rational agreement can be reached or that would settle all
conflicts between paradigms or world views. It is tempting to think
that the relative value of different therapeutic systems can be resolved
definitively through psychotherapy research. However, the evaluation
of therapeutic outcome is inextricably tied to values and shades of
meaning (Messer & Warren, 1990). This is unlike the situation
in engineering where a bridge will collapse if the correct method
of building it is not employed, or in medicine where a child will
die if an incorrect procedure is applied to repair a heart valve.
For example, if an individual comes to accept her shyness and finds
meaning in it, can we consider it a good outcome, or does there have
to be a substantial reduction in her shyness? Gandhi (1957) maintained
that his own shyness had become one of his greatest assets, since
it forced him to think before he spoke. If an individual loses his
phobic symptoms upon joining a cult, should this be considered a good
outcome? Rilke, one of the great poets of the twentieth century, chose
to cultivate his pain and solitude in order to deepen his art. Would
Wittgenstein's life have been "better" if he had been happy in the
conventional sense? Of course there are some outcomes on which most,
if not all, clinicians will agree. For example, few clinicians would
argue that reducing suicidal behavior is not a desirable outcome in
the treatment of a severely depressed patient. Differences will, however,
emerge when it comes to other types of outcome with the same patient.
For example, the existentially oriented therapist is likely to be
more concerned with helping him or her to live authentically than
the cognitive therapist.
Metatheoretical systems are best thought of as multiple lenses,
each of which can bring into sharper focus different phenomena and
different aspects of the same phenomenon. For example, while tragic
and comic visions cannot easily be integrated they can each be usefully
brought to bear in different clinical contexts, and in highlighting
different dimensions of one person's experience. This can be conceptualized
as a type of dialectical thinking that allows one to take into account
the paradoxes and contradictions that are inherent in life.
A long term psychoanalytic therapist may be suspicious of the good
outcomes reported by short term behavior therapists, seeing these
as superficial and unenduring. From a short-term behavioral perspective,
the psychoanalytic emphasis on structural change may be viewed as
presumptuous insofar as the therapist claims to know what changes
clients need to make. Dialogue about this type of issue can lead to
questions such as: How ambitious should the therapist be regarding
change? How should the therapist and client negotiate differences
in desired outcome? When should a reemergence of a problem be considered
a relapse, and when should it be considered a new problem? What types
of change should health insurance pay for?
This is not to say that research is irrelevant or that clinicians
should feel free to define outcome as they will. Rather, different
kinds of outcomes emphasized by different therapies must be viewed
within the context of the values and visions of life each holds to
be true, and this multiplicity of values is merely a reflection of
the complex nature of life. Psychotherapy integration does not solve
this problem, but serves to highlight it. A postmodern perspective
directs us to confront this complexity rather than to gloss over it
or ignore it. It encourages us to engage in ongoing dialogue with
colleagues who hold different world views. It also encourages dialogue
with clients about the tasks and goals of therapy. This type of negotiation
constitutes an important part of the process of establishing a therapeutic
alliance (Bordin, 1979).
The recent shift in behaviorally oriented theory towards an emphasis
on self-acceptance rather than self-control (Jacobson, 1994), provides
an example of the type of metatheoretical elaboration that can result
from dialogue among different theoretical traditions. Although it
has not been uncommon for behavior therapists to borrow techniques
and concepts from other traditions, they are usually assimilated into
a fundamental world view which emphasizes the importance of self-control.
By explicitly proposing that change be viewed as self-acceptance,
an outlook typically associated with the experiential tradition, Jacobson
is challenging the underlying paradigm through which change is understood.
The resulting shift does not necessarily have to radically change
the specific techniques that are employed, but the different ends
to which they are put may affect their ultimate impact.
Messer (1992) has referred to this kind of importation of concepts
as "assimilative integration" (pp. 151-155). It is the incorporation
of attitudes, perspectives, or techniques from one therapy into another
in a way that is cognizant of how context shapes the meaning of foreign
elements. This mode of integration favors a firm grounding in any
one system of psychotherapy, but with a willingness to incorporate
or assimilate perspectives or practices from other schools (see also
Stricker, & Gold, 1996). This is an evolutionary process in which
the contact with difference leads to a de facto, even
if unacknowledged, integration. However, to carry on such a dialogue
with the other in a meaningful fashion, one must be knowledgeable
about and firmly rooted in at least one tradition, and know where
one stands.
Integration at the Epistemological Level
Different therapeutic traditions tend to be associated with different
epistemological stances, and this also creates an obstacle to integration.
A survey by Morrow-Bradley and Elliott (1986) found that, in general,
practicing therapists find little of value in psychotherapy research,
and that psychodynamically oriented therapists are less likely to
make use of psychotherapy research findings than are their behavioral
peers. The behavioral tradition subscribes to the epistemological
stance of logical empiricism (Scriven, 1969) and its associated methodology
of experimental research. The empirical/experimental method of truth-seeking,
which psychologists have adopted from the natural sciences, relies
heavily on observation, laboratory studies, elementism, and objectivism
(Kimble, 1984; Krasner & Houts, 1984). It stems from the philosophy
of scientific modernism which includes the belief that nature has
an existence independent of the observer and is accessible to the
operations of the human mind (Schrodiner, 1967). Findings are presumed
to be context-free and lead to universal, nomothetic laws.
Psychoanalysis, by contrast, has traditionally been associated with
an epistemological stance which is more hermeneutic in nature (Messer,
et al., 1988). Under Brentano's influence, Freud distinguished psychology
from the natural sciences and instead developed a "descriptive science
based on the direct observation of psychological life, with a focus
on its meaning" (Wertz, 1993). Psychoanalysis was thus originally
understood to be a descriptive and interpretive science rather than
an experimental one.
Proponents of psychoanalysis have, to some degree, accommodated
themselves to the cannons of experimental research. But, as Hornstein
(1993) has stated, "American psychologists did to psychoanalysis what
they did to every verstehen-based psychology that arrived on the boat
from Europe--they ignored its underlying assumptions, skimmed off
what they could use, and repackaged the remaining content in the sparkling
language of positivist science" (p. 586). Even while this synthesis
of psychoanalysis and experimental method took place, there was never
any extensive debate about the fundamentals of scientific practice
(Hornstein, 1993). This may account, at least in part, for the failure
of experimental research to have had a substantial impact on the practice
of psychoanalytic therapy.
For some time now, there has been a call for methodological pluralism
in psychology (Polkinghorne, 1984), which we endorse as an important
feature of postmodernism. Cook (1985), for example, recommends agreement
from independent epistemological perspectives as the best foundation
for approximating truth. Similarly, Bevan (1991) warns us to be wary
of rule-bound methodology. "Use any method with a full understanding
of what it does for you but also what constraints it may place on
you...Be mindful of the potential value of methodological pluralism"
(p. 479). Such methods may include traditional experimental research,
case analysis (both quantitative and qualitative), skilled reflection
(Hoshmand & Polkinghorne 1992), phenomenological description,
anthropological field studies, action research, and narrative approaches.
Calls for methodological pluralism, however, come up against strong
emotional barriers. Hudson (1972), in a book with the ironic title,
The Cult of the Fact, suggests that experimentalists (the "tough-minded")
tend to think of nonexperimentalists (the "soft-minded") as sloppy,
even morally remiss, in their unwillingness to treat hard data seriously.
Nonexperimentalists, on their part, tend to view experimentalists
as mechanistic, dehumanizing, and simpleminded. Part of what is at
stake here is the question of what constitutes "science." A number
of philosophers of science from Kuhn (1970) onwards have demonstrated
that the process through which science evolves is very different from
the picture portrayed in the "standard view" of science (Manicas &
Second, 1983). Science has an irreducibly social and interpretive
character. Data are only one element in a rhetorical process through
which members of a scientific community attempt to persuade one another
(Weimer, 1979).
The rules and standards of scientific practice are worked out by
members of a scientific community and are modified over time. Many
contemporary philosophers and sociologists of science assert that
the demarcation criteria between "science" and "non science" are not
as clear-cut as they were once thought to be. They argue that the
logical empiricist view of science is a reconstruction according to
certain criteria of rationality rather than an accurate portrait of
the way science really works (Bernstein, 1983; Feyerabend, 1975; Houts,
1989; Kuhn, 1970; Safran & Muran, 1994; Weimer, 1979). The "research-practice
split" is thus, in part, fueled by the same type of marginalization
of the "other" associated with the contest between different therapeutic
orientations.
Beyond Relativism
The appreciation of the relative merits of different psychotherapies
within a pluralist outlook, and the willingness to engage in informed
debate about philosophical and epistemological issues can lead to
the conclusion that all are equal and "anything goes". That is, one
can confuse openness to other approaches with a kind of intellectual
anarchy or wishy-washiness. A relativistic position is said to characterize
our culture in this postmodern era in general. It has led critics
(e.g., Bloom, 1987) to argue that our culture lacks fundamental moral
and political convictions and, in the current relativistic climate,
there is "no enemy other than the man who is not open to everything"
(p. 27).
Finding a stance that is both pluralistic and nonrelativistic is
a central concern for many contemporary philosophers, and a new understanding
of the nature of science is emerging (Bernstein, 1983; Gadamer, 1980;
Habermas, 1979; Rorty, 1982). A central theme in this understanding
is the importance of dialogue among members of the scientific community.
This emphasis on dialogue should not be confused with sentimentalism.
The point is an epistemological one. A central theme in the contemporary
philosophy of science is that our understanding of things is inevitably
shaped by our preconceptions. There are no theory-free observations
(Hanson, 1958). The reason that dialogue is critical is because it
provides a means of moving beyond our preconceptions towards a better
understanding of the things themselves (Gadamer, 1980). Through the
process of recognizing our preconceptions and engaging in dialogue
with that which is alien, the possibility of seeing beyond our preconceptions
emerges. True dialogue involves seeking to listen to and understand
what the other is saying, and a willingness to test our opinions through
such encounters. Rather than a facile acceptance of alternative positions,
true dialogue involves an active engagement in the process of truth
seeking. This recognition of the importance of dialogue emerges out
of historical and sociological analyses of the way science actually
operates rather than the way it should operate. Scientific practice
involves deliberation among members of the scientific community, interpretation
of existing research, and application of agreed upon criteria for
making judgments and debate about which criteria are relevant. The
absence of absolute foundations is not equivalent to arbitrariness.
Bernstein (1993) refers to the underlying philosophical position as
one of "engaged fallabilistic pluralism." This means "... taking our
own fallibility seriously - resolving that however much we are committed
to our own styles of thinking, we are willing to listen to others
without denying or suppressing the otherness of the other" (p. 336).
A parallel can be drawn between scientific practice and the process
of making judicial decisions (Bernstein, 1983; Polanyi, 1958). Principles
of judicial arbitration evolve over time through rational deliberation
and precedent. Evidence plays a critical role, but this evidence is
always subject to interpretation. Each case must be dealt with in
its particularities. Rather than applying universal principles, general
rules of argument are given more or less weight depending on the specific
nature and circumstances of the case. These contextual features of
common law do not make judicial decisions "irrational" or "nihilistic",
but they do make it impossible to adequately model them through universally
applicable algorithms.
We are thus advocating ongoing dialogue at all levels of analysis
-- empirical, theoretical, metatheoretical and epistemological --
and not an uncritical acceptance of all therapeutic orientations and
techniques. The challenge that psychotherapy theorists and researchers
face as we enter the twenty-first century is one of learning to live
with an irreducible ambiguity, without ignoring it and without wallowing
in it (Bernstein, 1993).
Implications for Theory, Practice and Research
What are the implications of pluralism and contextualism for psychotherapy
theory, practice and research? At a theoretical level we have
highlighted, in accordance with pluralism, the importance of maintaining
a continuing dialogue among multiple perspectives. Rather than aspiring
to one superordinate theory, such a dialogue leads over time to a
degree of assimilation of ideas and techniques from one theory or
therapy into another.
One might argue that there is a contradiction between stressing
appreciation for the "otherness" of the other, all the while
critiquing the different forms of integration and advocating some
assimilation of them. Critical analysis, however, is part of the dialogue.
Although there is an inherent tension between appreciation of difference
versus a critique or assimilation of differences, we have argued for
a dialectical process between them, and not a facile or wholesale
acceptance or rejection of difference.
In line with a contextualist viewpoint, theoretical dialogue must
be grounded in the specifics of clinical practice. Just as study of
a culture requires tacking back and forth between theory and observational
detail, a theory of therapy has to be embodied in the particularities
of practice. It is not enough, for example, to discuss the differences
between transference and stimulus generalization in theoretical terms.
Comparison on the theoretical level must be grounded in clinical material.
Cultivating an attitude of astonishment among psychotherapy researchers
and clinicians can play a critical role in creating a climate conducive
to presenting videotapes and audiotapes of actual clinical material
in public forums, thereby facilitating clinically grounded dialogue
across theoretical orientations.
An implication of pluralism for practice and training in
psychotherapy is that we should be fluent in more than one therapy
language and mode of practice (Andrews, Norcross, & Halgin, 1992;
Messer, 1987). In the same way that one has to spend time in other
cultures in order to truly understand them, one has to immerse oneself
in other therapeutic orientations in order to be able to appreciate
their strengths and recognize their limitations. Clinical psychology
programs are too often conducted within one theoretical perspective,
which does not allow students to be "multilingual" and "multicultural"
in relation to the multiplicity of existing therapeutic languages
and cultures. Aside from book knowledge, the best ways of learning
about other approaches is to be supervised in their practice or to
experience them as a client.
While pluralism emphasizes our attaining knowledge of several approaches,
contextualism highlights the need for clinicians to evaluate a technique
they incorporate from a different orientation in the ongoing context
of therapy. A technique takes on the coloring of its surround and
it must be assimilated in such a fashion that it fits comfortably
within the theoretical and clinical framework into which it is imported.
One must attend carefully to the effect on clients of such a change
in the therapist’s manner, perspective, or technique.
Regarding the implications of postmodernism for research,
it is important to find ways to take into account the context and
complexity of clinical phenomena. A finding from a randomized clinical
trial that a treatment approach is effective with singly-diagnosed
clients, does not speak sufficiently to the practicing clinician who
has to work with complicated (often dual-diagnosed) clients whose
nuances of personality and psychopathology are not readily captured
by their diagnosis or the research protocols (Fensterheim & Raw,
1996; Goldfried & Wolfe; Safran & Muran, 1994; 1996). Group
designs which study subject variability are unable to mine the context-rich
information that can be extracted from the study of intrasubject
variability. Although it is difficult to generalize from such single-subject
research, this can be accomplished by multiple replications or by
combining intensive and extensive analysis (Barlow, 1981; Greenberg,
1986; Kazdin, 1982; Messer & McCann, in press; Safran, Rice, &
Greenberg,1988).
Thus, research comparing different treatment modalities at a global
level (e.g., cognitive therapy versus interpersonal therapy), or examining
client by treatment interactions, should be augmented by research
that investigates specific interventions that are effective in specific
contexts and the processes that underlie such change. For example,
Safran and colleagues (Safran, Crocker, McMain & Murray, 1990;
Safran, Muran & Samstag, 1994; Safran & Muran, 1996) have
developed an empirically based model of the processes that lead to
the resolution of ruptures in the therapeutic alliance. This model
specifies which specific therapist interventions will be effective
in the context of specific client processes along the pathway to resolution.
Messer and his students have studied the effect of therapists’
competence and their adherence to a psychodynamic focus on the ongoing
progress of individual clients. Raters had access to the flow of clinical
material thus allowing context to affect their ratings (Messer, Tishby,
& Spillman, 1992; Tishby & Messer, 1995). Collins and Messer
(1991) adapted Plan Formation methodology (Curtis, Silberschatz, Sampson
& Weiss, 1994) to study how case formulations are influenced by
the context of a rater’s favored theory.
A fruitful strategy for promoting the development of integrative
knowledge can consist of identifying important therapeutic contexts
or markers (Rice & Greenberg, 1984) that may be responded to differently
by therapists with different orientations (Safran & Inck, 1995).
For example, how do different traditions respond to instances of patient
self-criticism or to defensive maneuvers? Are there markers that are
favored by, or unique to, specific orientations? By working with these
smaller units of analysis (i.e., intervention A in context B) there
is an opportunity to get beyond name brand theories, allowing the
results to become more accessible and relevant across traditions.
It is also closer to a level that is meaningful to clinicians and
therefore can be used to guide practice in a complementary way to
randomized clinical trials.
Thus, research programs consistent with the spirit of integration
need not necessarily evaluate the effectiveness of integrative treatment
programs per se. When researchers dialogue with one
another, within a spirit of pluralism, around the kind of process
research just described, they can more readily absorb results stemming
from other viewpoints because it gets around their emotional attachment
to a brand name therapy.
Another implication of pluralism for research is the importance
of being open minded about methods other than those that are experimental
or correlational. Each method has its assets and shortcomings but
too often we sacrifice richer, contextual meaning for exactness and
narrowly focused certitude. Some combination of quantitative and qualitative
methods employed within the same research paradigm, for example, may
lead to a better understanding of the complexities of psychotherapy
than either approach alone.
Conclusion
In summary, the development of an open and engaged stance towards
integration among theorists can lead to more fruitful cross-theoretical
dialogue rather than the advocacy of a premature, unified paradigm
(see Mahoney, 1993; Stricker, 1994). The greatest value of the psychotherapy
integration movement lies in the creative and growth oriented confrontation
with and dialogue about difference, and it is in this process that
the payoff lies.
Our call for a more contextually based, pluralistic approach towards
psychotherapy integration may seem to some to invite unnecessary complications
into a field which is already complex enough. To be sure, there are
times when the strategy of simplification through ignoring context
or alternative perspectives is the most appropriate way to proceed.
Ultimately, it may be best to pursue an ongoing dialectic between
the strategy of simplification and that of thick description (cf.
Elliott & Anderson, 1994).
The search for a single, unified therapeutic model and laments about
the preparadigmatic and unscientific state of psychotherapy theory
stem from a misunderstanding of the nature of science. In the natural
sciences it is recognized that multiple, contradictory theories are
necessary to capture different aspects of the underlying phenomenon,
and that a given theory captures some of these aspects at the expense
of others (Nozick, 1981). Moreover, contemporary philosophers of science
state that science evolves through methodological pluralism rather
than a uniform set of procedures and criteria.
Over a century ago, John Stuart Mill (Cohen, 1961), a strong advocate
of empirical methods in scientific procedure, argued that a plurality
of views is critical for the following reasons:
1. A view which one rejects may be true nevertheless, and to reject
it assumes one's own infallibility.
2. A problematic view may contain some portion of the truth since
the prevailing view is never the whole truth. It is only by collision
with contrary opinions that the remainder of the truth has a chance
of being recognized.
3. A point of view that is wholly true, but not subjected to challenge,
will be held as a prejudice rather than on a rational basis.
4. Someone holding a particular point of view without considering
alternative perspectives will not really understand the meaning of
the view he or she holds.
5. Decisive evidence against a perspective only can be articulated
once an alternative perspective is advanced. This results from the
fact that evidence in the absence of theory is meaningless.
Both psychotherapy integration and science flourish in an atmosphere
of confronting and discussing difference rather than shunning it.
Once an integrative system becomes codified, creativity and openness
whither. One can become an adherent of an integrative system in the
same way that one becomes a cognitive therapist, a Freudian, or a
Jungian. A theoretical system is always in danger of becoming a fossilized
remnant of what was once a vital insight, even in the hands of the
person who developed it. It was presumably for this reason that Jung
once remarked (in Progoff, 1953): "I am not a Jungian and I never
could be."
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Author notes: This article represents the equal participation
of both authors. We thank Daniel Fishman, Antonia Fried, Robert Elliott,
Roger Peterson, and James Jones for their helpful comments.
Correspondence concerning this article should be addressed either to
Stanley B. Messer, Graduate School of Applied and Professional Psychology
Rutgers University, P.O. Box 819,
Piscataway, NJ 08854
Phone: 908-445-2323
Fax: 908-445-4888;
e-mail: Smesser@rci.rutgers.edu;
or to Jeremy D. Safran,
New School for Social Research,
65 Fifth Avenue, New York,
NY, 10003;
Phone: 212-229-5765;
Fax: 212-989-0846;
e-mail: Safranj@newschool.edu
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