Psychotherapy Integration Papers

Tullio Carere, March 23, 2009

Rebecca, I understand, from the commentaries to your book, that you bring together and try to integrate data from two different domains: in Paul Wachtel words, those deriving "from systematic empathic immersion in the experience of another person" and those deriving "from controlled experiments, technological innovations in brain scanning, and other methods more conventionally thought of as 'scientific'". The word 'scientific' is aptly put in quotes by Paul, to mean that this is what is 'conventionally thought' to be scientific. More explicitly, the current convention is that only systematic collection and statistical elaboration of measurable data produces something that deserves to be called science. All data collected with different methods are more or less, in Shaver words, just 'verbiage', i.e. "words about words, speculative theories about prior speculative theories–bad poetry".

Maybe we'll have all to admit that this is not conventional science, but just science, its methods being basically the same in natural and in human sciences. We'll have to swallow the bitter pill: there is only one science and only one scientific evidence: the empirical. Or maybe not. But those who are not willing to surrender to the one science cannot possibly go on doing their business as usual, with all and every psychotherapy school producing their own brand evidence. Brand evidence (psychoanalytic or else) is most probably at odds with scientific evidence, but is empirical research the only way to overcome the school narrow-mindedness to reach a reasonable intersubjective consensus, across different theoretical persuasions? Or, in other words: is there just one or more than one science for psychotherapy?

Tyler Carpenter, March 23

I suspect that there is likely a good panel and paper, if not journal volume dedicated to the topic, Tullio. The following article: Slife, B.D. (2004). Ch. 3: Theoretical challenges to therapy practice and research: The constraint of naturalism. (Ch. 3, pp.44-83) In M.J.Lambert (Ed.). Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (5^th Ed.), (Ch. 3, pp.44-83). New York: John Wiley -- is a nice introduction to relevant epistemologies. Your point is an important one that I devoted part of a lecture on for my Adult Psychopathology class and transformed into the following mid-term question they are answering as we speak (I guess this should be a Twitter, right?!)

By comparing Jack Kerouac’s hero Dean Moriarity in the beat and cultural classic “On the Road” to the diagnostic concept of a psychopath or antisocial personality disorder, we have a stark contrast between models of normal and deviant human development. Do the DSM and artist’s views of the world have different underlying assumptions and of what relevance are these sharp contrasts to understanding human development and normal functioning? You are free to use another example from cinema or literature or music, e.g., Les Miserables, Biggy Small, etc., if you wish as long as you address the central points of your argument in the examples with reference to the different models of human development. Hint: Consider Slife’s models of epistemology and Paul Rock’s description of Labelling Theory for some ideas about how the theoretical concepts we hold and the understanding of an individual’s life over time may shape how we and others see and deal with them.

Since most here I assume are familiar with Victor Hugo and Jack Kerouac, I think that brings the issue an immediacy and cultural closeness, that the student's referents to Hip Hop and Rap artists wouldn't (and vice versa).

Frankly I think we want to keep both models in mind for a variety of reasons that are important to aesthetics and culture and soul if you will, as well as good clinical care.

*Note: Paul Rock, a sociology/criminology Prof @ the London School of Economics has a nice chapter in The Oxford Handbook of Criminology (2002) reviewing the sociological theories of crime; and, Northeastern University's Professor Nicole Rafter's "Shoots in the Mirror" is a nice overview of crime movies. If I remember correctly it was Rebecca who asked me to extend the reach of a workshop I was running at SEPI to tap into to the darker areas of normalcy. So for those wishing to work their "shadow" (by whatever means), these are a couple of good resources.

Michael Kilpatrick, March 23

The nascent character of this topic deserves greater attention than just a few e-threads. Nevertheless I can't resist...

I'll be presenting trends that indirectly relate to this topic in Seattle - principally the slow demise of empiricism in dealing with both hard and soft science evidentiary methods. The old dialectic involving the merits of empiricism as the gold standard is becoming somewhat moot. There are newer evidentiary methods emerging within the hard sciences that are undermining their relevance, such as theories involving converging evidence mentioned within the neurosciences and qualitative meta-analytics that relies on the findings of many perspectives to assess truthfulness. The causal empiricism has been the gold standard since the 18th-19th century was suited to tasks dealing with tangible observable phenomena, However, it has has become less relevant for tasks involving more subjective and modal logic common in the social sciences.

The point I make is that it is time the profession developed its own evidentiary methods and standard uniquely suited to evidencing meta-meaning from human behavior.

Making this quantum leap, out of the profession's current "hermeneutic aporia", is an essential next step in SEPI's history.

David Orlinsky, March 23

Hi Tullio & Rebecca (& all).

I have a comment/complaint to add pertaining to the text you quote of Paul Wachtel. You noted that therapeutic theory and practice is (or should be) based on both “systematic empathic immersion in the experience of another person” and “controlled experiments, technological innovations in brain scanning, and other methods more conventionally thought of as ‘scientific’”.

I wonder why the field of ‘psychotherapy research’ is not mentioned. If there is to be a ‘science’ of psychotherapy, should that not be based primarily on the systematic study of psychotherapy (including participant-observer reports by patients and therapists as its data, as well as experiments and naturalistic studies)? Psychotherapy research is a broad and active field of science that looks at therapeutic processes (of diverse orientations) as well as their determinants and effects.

To paraphrase the English poet Alexander Pope who famously wrote “The proper study of Mankind is man,” I would respectfully suggest that the proper study for a real ‘science’ of psychotherapy are the various psychotherapies, their patients and therapists, and the contexts in which they work together.

Rebecca Curtis, March 24

Hi, Tullio, Tyler, David, and all, Thanks for the comments.

First, there is, of course, psychotherapy research reported in my book. There is obviously other research as well. The book also has some ideas about ways I've just been trying to put knowledge together into some kind of coherent working model to deal with so many perspectives.

Tullio, in regard to "science," the word seems to have the broad meaning of a body of coherent knowledge and the narrow meaning of empirical research. There are many ways of knowing and empirical research is one of them. There are, however, many research psychologists in the US (I don't have much of an idea how common this is elsewhere) who only accept as anything worth discussing the data from controlled experiments and randomized clinical trials. To a large extent the different values led to a split from the American Psychological Association, which was considered to be too “clinical”, and the formation of the American Psychological Society (more "scientific'). I discuss the gap between psychoanalysis and clinical psychology in the US in my book, but I don't discuss the split of the "hard scientists" from our APA.

I do think at Sepi there is an openness to ideas and a lack of narrow-mindedness. Thanks again for the comments.

Tyler Carpenter, March 24

In an ironic way, such splits in our professional communality (not to either fetishize or go Ronnie Laing or knotty on the topic) mirror in part the splits and compartmentalizations we seek to deal with in our patients. This distinction aside, the larger issue in my mind is not whether or not "empirical" research is integrated with that of a more phenomenological sort, but how best to integrate research from converging areas at other systems levels, e.g., psychopharm, neuroscience, multi-systems, etc., in a way that both preserves the integrity of the ideas and issues stimulating the discussion, but also result in creative clinical, research, and policy innovations that are responsive to the economic, health care, and limited resource demands we are wrestling with not only as professionals, but as consumers and tax payers. The implicit radicalization of achieving social justice by some sort of politicized redistribution of outsize corporate payouts is a ghost from the 60s or the preconscious, depending on the model and type of discourse at play. From the point of view of a public service clinician and former researcher who has watched funding for such work evaporate and the nature of the presenting clinical problems balloon past the point they can be either easily operationalized by researchers or addressed using extant models, I wonder if we can bootstrap the old arguments and polarities in a way such that integration moves in the direction of moving more broadly across systems and adapting down to the level of sessions such that people with truly complex problems, limited resources and time, can hope to have us as professionals usefully address their crises in real time, measure how effectively we are doing it, and teach the onrushing generations how to accomplish this feat.

When I wrote and published my two integrative articles in 1976-77 as a 26 year old trying to get a doctoral program to take a chance on me, psychotherapy integration was moving from the dark days of internecine disputes into some sort of rapprochment and civilized discourse. This was accomplished and a Toffleresque next wave is over due. Although as someone who has worked with sex offenders, and as an outsider discovered postmodern concepts like an exotic cigarette stub when I needed a smoke, I have a fondness for the sound, power, and meaning of words like fetish. Nevertheless, as a worker in the penal system I am inclined to want to "pull everyone's coat to it" and suggest that we unpack our terms and regard them as the transitional objects that they are and make some more concrete moves toward re-inventing ourselves yet again.

IMO most of the patients our students encounter in the clinics we supervise them in require diagnostic formulations and treatment plans that are beyond the models we routinely teach in our classes or use in our supervision. Frequently if not routinely the subjects that are studied are of a purity of presentation (though sometimes this is due to failure to control relevant variance out of lack of requisite knowledge or limited resources) that is rarely encountered in the real clinical world. Conversely, IME there is a corresponding lack of clinical appreciation and usage of routine multi-disciplinary empirical research findings by your average working clinician. I think that energy expended is best used in the service of closing some of the old rifts and the institutions they spawned and moving towards more robust and realistic conceptual, research, and clinical applications. If this sounds a little like the evolutionary approach that is unfolding in our communal economic marketplace, I doubt that should surprise anyone in this group. I don't believe anyone truly believes or has believed that any of the extant problems are emergent in a systemic vacuum or that any durable solutions will spring fully formed from Zeus' skull.

Paul Wachtel, March 24

Hi David,- I no longer remember the full context from which the quotations Tullio cites came, but it was from an argument in which I differed from Tullio in not advocating radically different separate-but-equal approaches, but rather being concerned with finding evidence appropriate to the subject being studied. That means, to me, that on the one hand, we don't fetishize particular methods if in order to pursue them we need to forego the phenomena we are interested in in the first place (e.g., those who only consider randomized controlled trials and manualization to be appropriate ways to study psychotherapy outcome -- which, of course, means that by definition a non-manualized treatment cannot be empirically supported or that treatments for "real people in real clinics" with messy multiple problems cannot be investigated). On the other hand, it means to me that much "clinical" writing -- in which we have to take the therapist's word for it that his recollection of what happened three weeks ago is an adequate substitute for the taping he or she perfectly well could have employed to attempt a more systematic study that is thoroughly rooted in the very phenomena he deals with every day in his office -- is insufficiently attentive to the capacity for self-deception and finding what we want to find, the very point on which psychoanalysis and the "scientific method" converge. As you can see from the above, I in no way intended to exclude psychotherapy research. You might find of interest the attached article of mine on these and related topics from the Journal of European Psychology.

David Allen, March 24

Hi everyone,

I agree with Paul that many of the change methodologies for human psychology and interpersonal processes, because of their complexity, are nearly impervious to randomized controlled studies. Additionally, as we all know, while RCT's are extremely valuable, they are at least as subject to experimenter bias (particularly in the way they are constructed) as are observational studies.

Below I've included a few excerpts from an unpublished book I've written for lay readers that addresses these issues that some of you might find interesting. (The problem of bias in so called empirical studies is just as applicable to drug studies as it is to psychotherapy studies - as I describe in detail in another part of the book. Clinical experience counts!).

Any responses or criticisms are welcome.

Much of human behavior, relationships, psychological processes, and psychotherapy methodology is simply not amenable to traditional scientific study designs. First, we cannot read minds, so scientists have to infer what is going on in there from the patient’s overt behavior or from what patients say about themselves. The psychological effects of interpersonal and family relationships in particular are virtually impossible to study strictly within the parameters of most empirical or supposedly unbiased scientific studies. This is because of their staggering complexity.

For example, how is it possible to precisely measure and quantify how individuals in a relationship understand and react to the shades of meanings involved in their verbal and non-verbal communication? It cannot be done. During any relationship, the feelings, thoughts, and intentions of each individual, as well as their ideas about the feelings, thoughts, and intentions of the other person, are constantly in flux as ongoing feedback from the interpersonal environment is perceived and processed. Additionally, memories of events from the entire history of any relationship are figured in to the assessment of relationship events by the principals. This prior history continually affects each person’s ideas about what is transpiring in the present and how he or she should respond to it. Two people in a relationship are engaged in an ongoing, complex, unscripted, and intricate dance in which they may be attempting to outmaneuver one another.

While every encounter between the two people in the relationship has familiar elements, every encounter is also somewhat different, and therefore different and at times novel responses are required. The understanding of these continual feedback loops between two persons in a relationship is one of the strengths of family systems theories and therapy, as will be described in Chapter Nine. The multiplicity of forms that results in both the uniqueness of each encounter and the repetitiveness of themes within them can be best appreciated in the context of an ongoing relationship between an observer and the observed.

Family members will often not even tell therapists or researchers the truth about what is transpiring within their family until they develop a trusting relationship with them. Developing trust can take weeks or months. If people see a researcher for a relatively brief interview, this will never happen. Even after trust has developed, much information is at first omitted. Trained therapists can pick up on recurring tendencies and problematic behavior only by listening to the stories patients tell about themselves.

Pattern Recognition

Humanistically-oriented therapists listen to countless little stories patients tell about their relationships. When patients are asked to free associate about their psychological problems – that is, report their thoughts in stream-of-consciousness form without self-censorship – they recount of an average of three little relationship vignettes per hour.As the therapist hears more and more of these stories, subtle repetitive patterns begin to become apparent. The longer patients stay in therapy, the better the therapist is able to understand them and the nature of these recurring patterns in their lives.

This sort of pattern recognition is something computers are not able to do well, at least so far, because recognizing them requires an understanding of common themes that recur in stories that may superficially sound unrelated. Such patterns are also unlikely to emerge in a single diagnostic interview or a psychological test of any sort. Engaging in long term psychotherapy with a patient is not only the best way to elicit recurring patterns, it may in many cases be the only way.

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The validity of some anecdotes was illustrated by a tongue-in-cheek journal article by GC Smith and JP Pell circulating on the internet, entitled “Parachute Use to Prevent Death and Major Trauma Related To Gravitational Challenge: Systematic Review Of Randomized Controlled Trials.” The authors pointed out, after a review of the literature, that there are no randomized placebo-controlled studies that prove that parachutes prevent deaths or injuries for people who fall out of airplanes. A placebo is an intervention known to be ineffective.

They concluded: “As with many interventions intended to prevent ill health, the effectiveness of parachutes has not been subjected to rigorous evaluation by using randomized controlled trials. Advocates of evidence-based medicine have criticized the adoption of interventions evaluated by using only observational data. We think that everyone might benefit if the most radical protagonists of evidence-based medicine organized and participated in a double blind, randomized, placebo controlled, crossover trial of the parachute.”

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The Problem of the “False Self”

People do not act the same way in all social contexts. They do not act or speak the same way around a boss that they do when they are alone with a lover. A man’s behavior in a strip club is very different than his behavior when he is playing with his children. We have different “faces” or masks which we apply to ourselves in different environments. Not infrequently, these masks are meant to manipulate others to get them to do what we want them to do.

The word “manipulate” has negative connotations, as if it means that we are trying to get others to do our bidding for some nefarious purpose. In truth, we all try to influence one another every day, and sometimes for noble purposes. We want other people to do things with us or for us, and at times we want to do things for them. In order to do this successfully, we must often hide our true feelings and inclinations. We may feign outrage or act warm and sweet when we are feeling some other way entirely. We are all actors. Being able to deceive other members of one’s own species under some circumstances has been shown to have survival value in primates.

In dysfunctional families, the masks that members wear are more pervasive. In order for members of such groups to affect other group members, they must often say or do extreme things which under other circumstances they might find unpleasant or even reprehensible. They develop what psychoanalysts have called a false self. Other terms for this are pseudo-self from family systems pioneer Murray Bowen, and persona, from Carl Jung. The behavior they present to the world in a variety of different contexts does not match the way they are really feeling inside. Such behavior becomes habitual and compulsive so they do not give themselves away accidentally when their guard is down. For this reason, patients in psychotherapy studies may be subconsciously motivated to act out their false self within the study, and appear in the final results to be something they are really not.

I never cease to be amazed at how mental health professionals and researchers seem to believe that they really know what is going on in a patient’s or a research subject’s life based solely on the self report of the patient, or solely on the reports of the patient’s intimates, or even on the reports of people like teachers who observe the behavior of children in only one context that involves thirty other distracting students. If these professionals were asked if they believe that people often act differently in public than they do behind closed doors, they would of course say yes, but they seem to develop amnesia for this fact in discussions and in studies.

A patient’s family members may be just as motivated to give a distorted view of a patient as is a patient. Parents, for example, may prefer to believe that their child has some sort of mental defect, so they do not experience as much of their own covert guilt about their parenting skills. Conversely, some may actually prefer to blame the child’s behavior completely on themselves, in order to let their “perfect” child off the hook. Most mental health practitioners do not make home visits to watch patients and family members interact in their natural environment. Even if they did, unless they had a camera operating twenty four hours a day as in the movie The Truman Show, they could still be deceived.

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...a so-called allegiance effect in RCT’s. The preferred psychotherapy school of the researcher is likely to be delivered more enthusiastically and with more rigor to subjects in the study than is the competing therapy treatment. One survey study examined 29 RCT outcome studies that compared one type of therapy to another and found a correlation of .85 between researchers’ therapy allegiance and outcome. That is, the researcher’s preferred treatment came out ahead 85% of the time. Just as in sponsored drug studies, this number is too way high for a significant bias in the studies to be discounted.

David Orlinsky, March 24

Dear Paul,

I appreciate your response. I realize that we probably agree very much about these issues. I was reacting more to what I perceive as a general tendency to look to ‘other’ sciences (e.g., neuropsychology, early child development) for concepts relevant to psychotherapy, rather than recognizing the important work in ‘our own’ field of psychotherapy research (which includes qualitative and systematic naturalistic studies as well as RCTs).

Tullio Carere, March 24

Paul Wachtel wrote:

I no longer remember the full context from which the quotations Tullio cites came, but it was from an argument in which I differed from Tullio in not advocating radically different separate-but-equal approaches, but rather being concerned with finding evidence appropriate to the subject being studied.

The quotations are from Paul's comment to Rebecca's book, cited by Rebecca in her first post. The argument to which Paul refers happened recently, on Paul's last book (I am going to edit and post it soon on the documents area of the SEPI web site). As Paul points out, our concerns in regards of science and psychotherapy are a little different. I don't mean to endorse false dichotomies, and I agree with Paul that we should be "concerned with finding evidence appropriate to the subject being studied". Many sorts of evidence are appropriate to the subject psychotherapy, some more than others, particularly as a function of the type of psychotherapy investigated. It seems clear to me, for instance, that a short-term, problem- or symptom-oriented treatment is in many respects quite a different thing than a thoroughgoing, open-ended therapy that considers problems and symptoms only in the whole of a person's life, her story, her relational context, her existential project. Randomized clinical trials can mean a lot for the former, almost nothing for the latter. It does not make much sense to me to be for or against psychotherapy research in the medical style. But it does make sense to note that this sort of research can be quite useful in problem-oriented psychotherapy, much less in process-oriented psychotherapy.

Paul and I agree on looking for evidence that is appropriate to the subject being studied, and I am sure Paul would also agree that, as psychotherapy is not a monolith, what is appropriate to a type of psychotherapy could not be appropriate to another. For instance, Paul finds audio- and video-recording of the session appropriate to his style of work, whereas to many, me included, audio- or video-recording is an intolerable intrusion in the intimacy of the therapeutic relationship, something that seriously alters the quality of the relationship itself--almost like having a video camera humming in your bedroom. Carl Rogers felt quite at ease doing therapy on stage, many or most psychoanalysts don't. Besides, in my view of psychotherapy my behavior--which can be recorded on tape--is not as important as the way my patient experiences it--which cannot be easily recorded, but can be monitored all the time in the session. What counts more in my way of doing psychotherapy is experience, not the way it is elicited. For instance, we all would probably agree that every patient needs to experience the therapeutic relationship as a secure base, where they can feel unconditionally accepted even in their more disturbing sides. But one patient feels safe and relaxed lying on a couch, whereas to another the couch is like a Procrustean bed; to one a silent analyst is a maternal womb, to another s/he is an hostile watcher.

In my and many others' view, the evidence that mostly counts is experiential, much more than empirical. As a consequence, what I need for my work is above all clinical research of the phenomenological type (it is not very relevant if the researcher has a psychodynamic, or cognitive, or whatever background, because the research is phenomenological to the extent that the observer can bracket out their theoretical persuasion). This type of research makes me alert to the typical patterns that I am bound to find in my work. For instance, my own phenomenological research has brought to my attention that patients usually bring to therapy their needs both to be accepted and confronted with their contradictions. With the acceptance-confrontation polarity in mind, I am better equipped to understand what particular combination of the two factors my patient needs in a given moment of the therapy or the session, I can try different ways to respond to these needs and adjust my responses according to the feed-backs the patient constantly gives to me. It is not that I shun other types of evidence. I am a psychiatrist, and frequently prescribe psychotropic drugs in the course of psychotherapy (even here though, what I pay attention to is the patient's experience of the drug, more than its biochemical, objective effect). What I reject is the claim that my experiential evidence is not an evidence at all, just "verbiage", or just a "hypothesis" in need to be empirically validated. Different types of evidence can be usefully integrated in the practice of psychotherapy. The danger that I see mounting is the pretence that only empirical evidence is properly an evidence, i.e. only empirical science is properly science.

George Stricker, March 25

Hi David,

Thus has been a fascinating discussion. My concern is with your initial statement in your very interesting material:

Much of human behavior, relationships, psychological processes, and psychotherapy methodology is simply not amenable to traditional scientific study designs.

In saying this, you equate "traditional scientific study designs" with randomized control designs, and I certainly would agree, if that is the definition. However, there are many approaches to research that qualify as legitimately scientific and allow the research much more flexibility. Correlational techniques in general, and particularly some multivariate designs, help to close the gap. I go back to what both Paul and the other David call for, the need for systematic study, as part of the solution. This also reintroduces the concept of the local clinical practitioner, an area in which I, of course, have a vested interest.

Alan Javel, March 25

I always wonder what our controls in research would be. If a placebo response is a psychological phenomenon, then all psychotherapy is placebo.

David Allen, March 25

Alan,

Your comment brings up an interesting paradox: we’re trying to be objective about subjectivity!

Paolo Migone, March 25

Of course all psychotherapy is placebo, in fact it is extremely effective. The definition of psychotherapy I prefer is something like: "Psychotherapy is nothing but the systematic and scientific study of the placebo phenomenon in order to understand it in its details and to replicate it, trying to make it as stable as possible and to share with the patient what we have understood".

Serge Prengel, March 25

I want to express both my deep appreciation and extreme frustration for this discussion. Both the appreciation and frustration have to do with keeping receiving e-mails that so beautifully articulate what it is that I was just in the process of writing in response to previous e-mails and this discussion. :)

Marco Giannini, Alessio Gori, March 25

Hi everyone,

as SEPI Members involved in organizing the Florence SEPI Annual Meeting, May 27th to 30th, 2010 we propose our point of view regarding the recent debate on Rebecca Curtis book.

According to Orlinsky we think that psychotherapy research is a field of science that looks at therapeutic processes (of diverse orientations) as well as their determinants and effects. Psychotherapy research, involves the systematic observation and analysis of these Four Common Factors:

1.Client;

2.Psychotherapist;

3.Relationship between client and psychotherapist;

4.Psychological, social, cultural, and biological contexts.

From our perspective people are viewed as byopsychosocial entities embedded in and continual transaction with dynamic environments. Therefore, all aspects of their lives are of potential importance. This ontology appears to be either a psychophysical interactionism or a double aspect monism .

What about data?

In psychotherapy research, observations can be analyzed either quantitatively or qualitatively.

Indeed, the process of psychological evaluation, in most cases, implicates a prediction. Our approach to modeling human behavior is to consider the human as a device with a large number of internal mental states, each with its own particular control behavior and interstate transition probabilities.

In other words, under this approach it is possible to identify some elements that make it possible to enunciate general explanatory propositions. The empirical data gathered through the observation, or the assessment process, is the premise (the point of departure) from which is possible to begin the clinical work. The process of clinical decision-making implicates various factors (examining symptoms, searching for clues in current behaviour or in history, outcomes prediction, treatment planning) that justify the use of different assessment techniques for establishing an integrative approach to intervention.

Serge Prengel, March 26

I would add the following consideration: That we place our comments on what happens in psychotherapy within the broader context of life & the human condition.

Here’s what I mean by this: When we just look at “exact” sciences, we can be led to think of the traditional, quantitative, “objective” avenues of knowledge as the norm. When we look at the whole of human endeavors, there is relatively little that lends itself to that kind of quantification, or “objectivity”.

I am not just talking about some of the biggest decisions we face in our individual lives, such as the emotional decisions we make about relationships or careers. For instance, in the current economic crisis, as well as in other major political crises, the "people in charge" are pretty much improvising as they go along. In terms of solving the economic crisis, or of dealing with global warming, we make decisions without a tested roadmap… or even without a “scientific” approach to making collective decisions.

By the way, in terms of politics or economics, being "empirical" means not being dogmatic; it means taking into account experiential feedback. In these fields, people who claim to rely exclusively on science are often dogmatic.

Putting therapy within the broader context of life & the human condition means that we keep being aware that what happens in a therapy session is very similar to what happens in life. We are all participant-observers in our own lives, as well as when we interact with others or advise them.

So this is the opposite f apologizing for not being a “real” scientific endeavor. It becomes a very real laboratory on how to deal with life.

Paul Wachtel, March 26

In thinking about the discussion that is going on, I think it would help to introduce some clarity if we retired -- or made more precise -- our use of the word "empirical." The issue, in most aspects of the controversy here, isn't about being empirical. It's about how to be empirical. What I mean is that formulating one's theories or one's ideas about a case formulation on the basis of clinical impressions is as "empirical" as doing an experiment. Both rely on "what we see." The problems arise in interpreting what we see, in knowing how, whether, or in what way to trust what we see. What is usually meant when the word "empirical" is used is really something like controlled observations. Both psychoanalysts and hard-headed "empiricists" agree that human beings have a prodigious capacity for self-deception, for persuading ourselves that we are seeing what we expect to see, what it makes us feel better to see, what fits with our biases, etc. The question then becomes how to deal with that tendency. We can never completely eliminate or overcome it, but we can at least reduce the likelihood that it is distorting our perceptions and conclusions.

The various methods of science -- experimental controls, double-blind evaluations, systematic correlations rather than "it looks like the more of this the more of that," etc are all ways to address this tendency. In a different way, the non-quantitative configurational methods of, say, historians or literary critics are a similar kind of effort. They aim to show what goes with what, what suggested relationships are accidental, what refinements need to be made to general conclusions, etc. These methods are not perfect (neither are those we call "scientific"), but like the methods of science they help to control for seeing just what we want to see, they are ways of weighing the evidence.

Historians or literary critics don't do controlled experiments because, by and large, they can't. So they do the best they can. The best of them develop methodologies that are as rigorous as possible for the subject matter they are addressing, and they make their choices based on an understanding that they might have greater reliability or validity if they counted instead of making an argument, but in doing so, they might end up having to stop concerning themselves with the very phenomena they are interested in. Their methods are very different from those of laboratory scientists, but their basic aim -- to pay attention to what can be observed, but to do so in a way that does the best job possible to correct for just seeing what you want to see -- is the same. In that sense they are all "empirical."

This does not mean that all methods are equal. Even in the "hard" sciences new studies are constantly showing how the previous studies left out crucial controls or in some other way were misleading. Wenever get it "perfect," never see nature with a God's eye view. But the best of us keep honestly trying to correct for our own tendency toward self-deception (while, inevitably, deceiving ourselves about how well we have corrected for that -- that is, for example, what has happened with the ideologically driven tendentious definitions of what it means to be "empirically validated" or "evidence-based.")

Clinicians often use methods akin to those of historians or literary critics. They do so, often, because for them too this is the best that can be done while staying true to the phenomena they wish to study. But we need to be constantly examining ourselves in this regard. Where Tullio and I have differed, for example, is in the value of audio and video taping as a step (always only a step) toward overcoming some of our tendency toward seeing and remembering what we want to see. We also have differed in whether the clinician can "bracket" his or her biases. I am much more skeptical about this than Tullio is.

All of these are important topics for us to be continuing to examine together. There is definitely no one "royal road" to validity, especially if we also value meaningfulness and fidelity to the phenomena actually of interest. But I think that if we make the kinds of distinctions I have just alluded to (I by no means view my suggestions as anything more than a first rough cut, hardly a scratch in fact), and make those kinds of distinctions, rather than "empirical" or not "empirical," we will have introduced at least some increment in clarity into our discussions.

David Orlinsky, March 26

Dear Paul, Tullio, et al.,

Unfortunately you have made this discussion too interesting to ignore, making it hard to get my other work done. :)

In the spirit of Paul’s last message, I was moved to offer some definitions that I think (hope) may be helpful. See below.

Science [in the old sense of L., scientia] = ‘systematic knowledge’ (as distinct from ‘opinion’).

Empirical = ‘founded on observation’ (including self-observation, participant-observation, and non-participant observation).

Empirical science = systematic knowledge based on (i.e., derived from, but not identical with, the observations taken as ‘data’). Historically, empirical science (re)emerged in the European Renaissance in contrast to other forms of knowledge (e.g., knowledge founded on tradition = ‘lore’; knowledge founded on revelation = ‘faith’).

Data [in the old sense of L.] = that which is ‘given’ and taken-for-granted as the starting-point for discourse. (NB: ‘data’ is not the same as ‘evidence’.)

Data [in the old sense of L.] = that which is ‘given’ and taken-for-granted as the observational starting-point for methodical analysis and theoretical discourse. (NB: ‘data’ is not the same as ‘evidence’.) Observational data can be based
(1) on self-observation, or ‘introspection’, (2) on participant-observation, or ‘experiential immersion’, and (3) on nonparticipant-observation, or ‘objective examination’.

Data can be analyzed (1) intuitively, by pattern-recognition; (2) qualitatively, by the articulation of patterns that have been recognized (e.g., as themes or narratives); (3) quantitatively, by counting the incidence and/or intensity and/or associations of articulated patterns and sub-patterns (‘elements’).

Empirical evidence [in the old sense] = that which has been ‘shown’ or ‘demonstrated’ to be validly held (‘true’) about observations that have been systematically collected and methodically analyzed.

Scientific theory = logically consistent (‘systematic’) concepts that function:

(1) to define what should be observed, how to observe it, and the appropriate conditions under which observations should be made; and

(2) to comprehensively account for (‘explain’ or ‘interpret’) the results of observations that have been taken as data, both within a given study and in relation to similar types of observation made in previous studies;

(3) to elucidate the implications of these ‘explanations’ for future research in further studies.

Scientific research-theories of psychotherapy = scientific theory (vide supra) in the context of systematic research on ‘psychotherapies’ (‘healing’ and ‘well-being-promoting’ practices that are engaged in through verbal and nonverbal symbolic action).

Clinical practice-theories of psychotherapy = logically consistent (‘systematic’) concepts that function:

(1) to aid the ‘therapist’ recognize and understand (‘assess’ or ‘diagnose’) the distressing, problematic, and ‘non-normative’ forms of experience and behavior of persons (‘clients’ or ‘patients’) seeking help individually, in relationships, or in groups;

(2) to guide the ‘therapist’ (a) in considering and selecting forms of response (‘interventions’) that are likely to be experienced by ‘clients’ (‘patients’) as helpful, and (b) in relating to individual ‘clients’ in the manner that is likely to be experienced by each ‘client’ as ‘facilitative’ or helpful;

(3) to generate introspective and experientially-immersed observations, and intuitive analysis, of personality, relationships, and groups, including the ‘distress’ and ‘problems’ that arise in them and the therapeutic procedures that help to ameliorate and resolve them.

Clinical-practice theories of psychotherapy serve very different functions than scientific research-theories of psychotherapy. Although they appear to deal with ‘the same’ subject, they do so in different ways and toward different ends. Conflating them with one another can only lead to confusion and the detriment of each!

Evidence-supported of psychotherapy = clinical practice guided by relevant research-based knowledge of psychotherapy, to the extent that the latter exists and with a clear recognition that research-based knowledge (however extensive) is inherently limited, partial, and probabilistic.

Mike Basseches, March 26

As with others, I find this discussion too interesting to ignore. I could contribute my two cents, but somehow the format seems inadequate. The questions raised, the novel ideas, research and practices that are consistently presented at SEPI meetings are always fascinating to me. However, there is something about these fundamental epistemological and human discussions (for Habermas, my favorite epistemologist of late -- epistemology is deeply grounded in the dimensions of the human condition) that seems to be at the foundation of everything we strive for as practitioners, as researchers, and as "explorers of psychotherapy integration". This exchange creates a longing in me for some open space for shared exploration and free-wheeling discussion of these issues -- to locate our essential agreements and disagreements. I know that it is late for this request and that Tullio, who has a knack for getting these discussions started, won't be with us in Seattle. But might it be possible to set aside some time for this during our conference? Just as one possibility, if we could find a room where we could all sit in a circle in a restaurant Friday evening at 8:30, or else a room in the conference hotel to which we could some have food brought in if we wanted, that would give us a chance to continue this discussion at greater depth. I guess I'm assuming that the several hours of "reception" before this might provide ample opportunity, both to catch up with old friends personally and to make new friends, which I know is an important function of SEPI meetings. If the past is any guide, the reception is also likely to provide enough food, that at least for me, the hunger for more food is likely to be less intense than my thirst for more of this discussion.

Anyway, I'd appreciate others input on this, including from the program/local arrangements committees as to relevant considerations that I may be failing to take into account. Also, regardless of whether or not we can do this in Seattle, I would ask the program committee for the Florence meeting (at which I expect to see Tullio) to consider ways of making space for this type of discussion. I would be happy to help with the responsibility for describing/convening/ moderating this kind of open discussion which happens inefficiently on the listserv if that would help.

Serge Prengel, March 26

I agree that the central issue is that “human beings have a prodigious capacity for self-deception (…). The question then becomes how to deal with that tendency.”

In “diagnosis” mode, the question could be:

-What would it be like if I were to consider this situation from another perspective than my “default mode” leads me to see it?

-Research would be helpful for this - not so much in predicting specific outcomes as in giving sense of what kind of journey to expect.

In “treatment” mode, the issue is to remain aware that the “progress” we are observing may largely be the “placebo effect” that results from the client experiencing interaction with a person perceived as competent, or caring (or both).

The questions, as a clinician, could be:

-Am I doing better than a placebo?

-What is it, in what I am doing, that might be working better than a placebo?

-this might lead to recognizing that it takes a lot of skill to be a good placebo.

David Reiss, March 27

Very interesting discussion! This brings me to a paper I started working on years ago, but never completed, applying chaos theory to issues of diagnosis and treatment: defining the various different contributory bio-psycho-social variables; showing that these are not independent, but inter-dependent variables; and therefore, to mathematically model and evaluate these issues, if you use a linear model, very significant data is lost and "averaged out", and the more accurate model would be a stochastic model based on partial differential equations, which cannot be "solved", but can be modeled using chaos theory.

If anyone would like to work with me further on this theory, please contact me...

Tyler Carpenter, March 27

I would be very interested, David, but my math is not @ that level. I became quite interested in the ways in which chaos theory offered a way to bring "order" to thinking about the extremes of behavior like acute psychotic episodes, serious aggression against self and other, and how one uses available resources, medications, and integrative therapies to modify the diathesis. It would be lovely to be able to put words on it as I seemed to be able to accomplish it in prison. Feels a little like a jazz player trying to explain a riff on an old standard. Similar, but never the same twice.

David Allen, March 27

I believed that there are ways to uncover bias both in "hard" empirical studies and "observational" empirical clinical experience. This is easier to see in the former, and I will use drug studies to illustrate. Obviously replication of studies is required to increase clinical confidence in results. Also in studies, one has to read the whole report very carefully. I have often found that conclusions stated in an abstract are not supported by the data presented in the article.

Also, drug companies have ways to "stack the deck" to make their product look better than it is. We already know that in the past they have deep-sixed negative studies, but that's only the most obvious use. They also pay folks to actively denigrate generic drugs (e.g. benzodiazepines) in throw-away journals and other publications. No studies combining say, an SSRI (or previously, an MAOI) and a benzo in patients with Borderline Personality Disorder have ever been done - despite the fact that many of us have been successfully using these combinations for over thirty years - let alone studies comparing that combination to an SSRI plus an atypical antipsychotic.

The manufacturer of Abilify is advertising that it "augments" antidepressants, when it fact it may just sedate the patient. And in their ads they make the misleading statements that only 30% of patients respond to antidepressants alone. That is only true if you include both dysthymics (less likely to respond) and people with true major depression (more likely to respond), if you only try one antidepressant, and if you don't pay attention to comorbid conditions, personality issues, stressful life events, and dysfunctional relationships.

There was an article in the New England Journal of Medicine, perhaps the most respected medical journal, that concluded that antidepressants were less effective than placebo in bipolar depressed patients already on a mood stabilizer. I know from my clinical experience that this is nonsense. What the article failed to mention at all was that many if not all of the subjects (it also didn't say how many) had already failed treatment with one or more other antidepressants. Another study has shown that switching to a new agent often works when one antidepressant fails, but every time you switch you get diminishing returns. The response rate if you only try one drug barely beats placebo in the first place, so of course if you try a second and only look at that, it appears that the drugs don't work! I e-mailed the NEJM article authors to ask how many of the subjects had failed a previous agent, and received no reply. Not surprisingly, every author of the article had a list of drug company connections a mile long.

As for clinical anecdotes, I offer the following (also an excerpt from my book):

Anecdotal Evidence: the Good, the Bad, and the Ugly

Anecdotal evidence in medicine is often misleadingly defined as evidence based on only one clinician’s personal experience with a treatment or diagnosis in question. If that is the standard that is to be used, clearly many reasons exist to question the validity of inferences drawn from these experiences. Individuals are well known to have various biases that color their observations and the conclusions they draw from them. They may have blind spots because of their own emotional conflicts. They may ignore evidence that is contradictory to their point of view. Their observations may be limited by their pet theories about the phenomena in question. They may be seeing unusual cases that are not representative of more “typical” cases in one way or another – a so-called selection bias.

An obvious case of selection bias was illustrated by a statement I heard made at a conference by a family therapy pioneer, the late Jay Haley. I had always admired Mr. Haley for many of his fascinating and utilitarian ideas and observations. However, in this case he betrayed some ignorance. He stated that he did not believe antidepressant drugs were ever effective because none of the patients referred to him had ever responded to them. Of course, his being a well-known family therapist who did not believe in medication had a tremendous effect on exactly who would be referred to him. Not everyone does respond to drug treatment. Anyone who had responded to an antidepressant would, in all probability, rarely if ever darken his door. Hence, with his sample, he would be misled into thinking that the medicines were not effective for anybody. This form of bias is very common and can be quite subtle. For example, it can affect one’s beliefs about such matters as racial stereotypes or a determination of how trustworthy members of a city’s police department are.

Descriptions versus Conclusions

Do these types of biases invalidate all clinical experience? Hardly. First of all, we have to distinguish between the descriptions of the actual events contained within specific anecdotes, and the conclusions or inferences which are drawn from these events. Let us examine the descriptions of what actually happened. A specific anecdote may be accurately observed and described, or not so accurately. If important details are altered or left out entirely, the anecdote may indeed be worthless. However, the exact same thing can be said about empirical studies.

Important details may not even be known to an observer. With observations of family behavior within a practitioner’s or researcher’s office, important information is almost always hidden. In addition to the fact that one does not see the whole picture in any single context, there is also a basic problem inherent in the nature of interactions between intimates. With verbal behavior, for instance, linguists refer to a quality called ellipsis. What this means is that in conversations among people who have known each other for a while, certain information is not spelled out verbally because the other person already knows it. Strangers such as therapists who are listening in and who have not been privy to these prior experiences may think they know what the family is talking about, but they may in reality be completely clueless.

In my talks to trainees, I often show a videotape of a grown woman bitterly attacking her father because he made her do chores when she was a teenager. Poor dear, she had to do chores. How terrible! Most viewers feel sorry for the gentleman until I let them know that one of her “chores” was providing her father with sexual release when he was between wives. Although neither the woman nor her father ever mentions this specifically on the tape, if the observer knows this fact, the real subject of the conversation becomes more and more clear as the session progresses.

Let us now consider the separate issue of conclusions that are drawn from anecdotes, as opposed to their description. The questions raised by an accurately-described clinical observation can be quite valid, but the answers inferred from it can be completely wrong. Conclusions based on clinical “anecdotes” exist on a continuum from relatively accurate ones to those that are extremely biased to those that are based on spectacular inferential or logical leaps of faith.

Relatively unbiased clinical conclusions based on anecdotes by mental health professionals have many things in common:

1. They are based on a sample that one has a reasonable expectation is at least somewhat representative of a larger population.

2. They make use, not just the practitioner’s observations, but of the observations of other professionals whom one knows to be reliable and open minded. These clinicians should also be ones known to take the time with their patients necessary to take a complete history.

3. They make use of other informants besides the patient when possible.

4.  They take into consideration that people and their family members behave quite differently behind closed doors than they do in public, and therefore if at all possible include observations of patient behavior when patients are unaware that they are being observed.

5. They are based on longitudinal observations. That is, the patients on whom conclusions are based have been seen on multiple occasions over an extended period of time.

6. They are not contradicted by commonly observed examples of behavior in everyday life related to the behavior in question.

7. The person proposing the conclusion acknowledges potential biases, such as a financial stake in a certain drug or allegiance to a specific school of therapy, and acknowledges his or her limitations. What former president of the Society of Clinical Psychology, Gerald C. Davison, calls “ex cathedra statements based upon flimsy and subjective evidence,” ¹³a hallmark of some psychotherapy gurus, are always highly suspicious. In fact, charlatans are relatively easy to spot. Their attitude is, “Trust me and just believe that my methods are highly effective.” According to Neil Jacobson, false prophets show no humility or doubt, exhibit an indifference to independent tests, and have a tendency to sidestep challenges. I give several examples throughout this book of so-called experts sidestepping questions, and will mention another shortly.

8. The conclusions reached should lead to predictions of patient behavior under certain circumstances that prove to be accurate in a significant number of cases. This is called predictive validity. Of course, human behavior being as unpredictable as it is, at times the predictions will not be completely accurate even if the conclusions are valid, and so this fact must also be taken into account.

9. Conclusions based on anecdotes about treatment efficacy or the reasons for certain observed behavior should consider several alternate possible explanations for the observations. If several explanations are possible, one must make a judgment about which ones are more likely and which are less likely based not on the anecdote alone, but on all sources of data available. These sources include empirical studies, but also include observations from everyday life, as well as material seen in some relatively reliable media such as reputable newspapers.

Now of course stories in the media may also not tell the whole story or be biased, so one needs to realize again that one can be fooled, and take this into account as well. I used to believe the common myth, for example, that in nature under certain conditions the animals called lemmings would follow each other off a cliff and commit mass suicide. I was surprised when I learned that this was untrue because I had as a child in 1958 seen a film clip of said mass suicide that was part of a Disney “True Life Adventure” nature movie called White Wilderness. I later learned that, because the Disney crew could not find a real example, they had from behind the scenes driven the group of lemmings off the cliff for the cameras.

On the other hand, many people believe that men have never been to the moon and that films of the moon landings were made in a movie studio using special effects. I must say, I tend to believe that those film clips are real, but few know for certain.

10. If other anecdotes about similar patients and treatments seem to contradict the conclusions based on a given anecdote, an attempt should be made to account for this difference.

As an illustration of the latter point and an example of a the “quick step side step,” I heard an expert present new evidence from neuroscience that certain capabilities of which human brains are capable seem to develop only at certain times during early childhood development. This brain development could be adversely affected by a baby’s early social environment. Of course, that is somewhat true. Like psychoanalysts will, however, the expert went on to conclude that if the adverse early experiences had taken place, the child had no chance of growing up to be normal. I raised my hand and asked about those children who come from horribly adverse backgrounds, are adopted away at an age past the alleged crucial developmental time, and yet still turn out wonderfully. The expert then changed the subject without ever addressing my question.

David Reiss, March 27

Two quick and superficial responses regarding David's notes:

1) Re: Ads for Abilify -- like we haven't been using low-dose neuroleptics as augmentation for severe but non-psychotic depression for at least 40 years? Those of us who remember Triavil -- the combination of Elavil and Trilafon, popular in the 1980's... (Although most of us shied away from using the fixed-dosage combination, preferring to titrate adding a few mg of Trilafon, Stellazine, Loxitane etc. to an anti-depressant regimen.) But Abilify is being advertised like this is a new and exciting theory... "NOT"

2) Regarding skewed research -- how many advertisements are placed in periodicals like "the Reader" for drug study participants? Yet have there been any studies on the psychosocial, socioeconomic, and characterological traits of those who would tend to respond to an ad for a research project (often for a stipend) in that type of periodical, versus an "average" patient? My hunch -- those participants are more likely to tend towards the histrionic/borderline spectrum, and/or feel more desperate, and unable to afford private treatment, and therefore, they are more likely to have a stronger placebo response within the early phases of what they are implicitly led to believe to be a "new and improved" treatment. It might be argued that in a blind study, they would not know if they are receiving the active agent under investigation or an actual placebo -- but realistically, considering that typically even the most benign psychotropics have some impact on affect or cognition, and some side-effects (even if minor) -- i expect that the majority of participants would know if they were taking the active agent. How might those dynamics and factors skew research results, especially in a relatively short-term study?

Tyler Carpenter, March 27

Dave's (superficial - NOT)observations point in at least two directions IMO.

The first is that judicious and thoughtful multidimensional treatment is likely unlikely to be reduced solely to placebo (too much heterogeneity as defined so far IMO). I "know" that what I treated in prison with adjunctive pharmacotherapy would not likely have been as ameliorative without the thoughtful chemical ministrations of our psychiatrists with whom I always actively consulted. The good response to changes in med dose and class, sometimes over years, only serve to drive this observation home. I also think that like the alchemists, history well may remember us for the by-products of our search and not any extra-ordinary and unusual discoveries. As Bernie Beitman suggested to me some years back @ SEPI, the patient's meds don't work unless they are in the right mental place. Or, I would add, in the right relationship. IME I've been the catalyst for many anti-psychotics contributing to the surcease of acute psychotic symptoms with both active and passive interventions ("meaning" + informed and adaptive action equals insight). I've seen others resistant to both the meds and hospitalization without the added effect of therapist.

Regarding the second point, one of the few things we didn't argue over, a "biological" psychiatrist and I who worked on a research project together for years, was the critical role of personality in any kind of successful treatment. He turned me on to a paper by two BPSI analysts who were psychiatric consultants and used a typology of character types to bootstrap their medical interventions and recommendations.. Lost my copy of their paper, but it was a jewel. I think however, we are all way to much like fish swimming in the water of our culture for me to ascribe much pathology to those who want a quick fix for their pain. Not an irrational choice unless it won't work. After all, SEPI came into being in certain times and not before.

David Reiss, March 27

In my experience, not only is the reaction to meds significantly impacted by characterological structure, well beyond the supposed "PDR" effects on symptomatology -- but there is also a relationship between the reaction to meds and the whole issue of personality fragmentation. I find that most obviously in borderline-spectrum patients. Even the subtle changes in manifest personality traits that may be the result of "micro" dissociation/fragmentation, impacts which meds they respond to, how well they respond, and the side-effects which develop. IMO, even subtle psychological dissociation/fragmentation correlates with certain subtle and poorly understood neurochemical changes. I work with patients to be able to learn and understand which meds are most effective when they are in different states of mind (not just regarding symptomatology). Without integrating psychopharm with psychotherapeutic intervention, there is at best a broad "shotgun" approach, and, in my experience, not infrequently, the result is significant episodes of iatrogenic counter-therapeutic responses. (More on this in my discussion group in Seattle...)

Tyler Carpenter, March 27

And that is how whole humans respond in truly observant treatment, Dave. I would love the PPs whenever. The sad thing is that while some very astute psychologists may achieve such synchronies in bio simple cases if they ever get Rx privs, in the places where they hope to justify their practice (geriatrics, prison, public sector), they like many of their medical bretheren and sisteren, are clearly out of their depth. My RN wife and I are in solidarity on this important acknowledgement to medical experience, but if I were to say this publically I would likely be ostracized by some psychologists.

Tullio Carere, March 29

The adjective empirical is usually employed by contrast with the merely observational, clinical or experiential. Empirical research is mostly meant as quantitative, statistically based research, as opposed to the qualitative, phenomenological or euristic type of research that does without measures. Paul Wachtel, with the aim (I believe) to avoid a not easily bridgeable dichotomy, suggests a larger meaning of the word: "What I mean is that formulating one's theories or one's ideas about a case formulation on the basis of clinical impressions is as 'empirical' as doing an experiment." This in fact is the original meaning of the word, as David Orlinsky points out--empirical as based on observation, rather than tradition or faith. Does it mean that all research, even that "akin to the methods of historian or literary critics", deserves to be called empirical to the extent that it is based on observation, and not tradition or faith? No. Not all observation is empirical, clarifies Paul: just controlled observation. Our observations must be controlled in order to fight our extraordinary and ever present capacity and willingness to deceive ourselves. This is what science is all about, argues Paul.

The various methods of science listed by Paul -- experimental controls, double-blind evaluations, systematic correlations, audio and video-recording of the sessions -- have all the same task: to neutralize as much as possible all subjective bias (our ways of deceiving ourselves) in order to approximate as much as possible objective truth. Indeed, this is basically the way modern science works, in all fields. Measures and controls are the core of the representational paradigm inside which modern or empirical science operates. We represent the world to ourselves, i.e. we build images and concepts of it. As our representations are imbued with our self-deceptions, measures and controls are mandatory to clean them as much as possible from all subjective contamination. In the representational paradigm we are free to espouse all the theories we like, provided that we are willing to put them to empirical test, i.e. to subject them to measures and/or controls.

I have nothing to object to empirical science, as long as one does not claim that it is the only possible science -- as I have nothing against the representational paradigm, as long as one does not claim that it is the only one capable of producing valid knowledge. I personally move inside a different paradigm, one that is sometimes called intentional -- intentionality being the orientation ad rem, to the things themselves, as opposed to the orientation to mental constructions. Yet I prefer to call it dialogic -- the essence of true dialogos being the willingness to suspend as much as possible all preconceptions and expectations (all memory and desire) in order to open a space (a Lichtung, a clearing) between the dialoguing persons in which the logos (the truth) of the process can unveil itself. It is not that there are no theories in the dialogic paradigm: but theory means here something different from the representational one's. It is the Greek theoria, which means contemplation, i.e. a mode "of being present in self-forgetfulness, and to be a spectator consists in giving oneself in self-forgetfulness to what one is watching. Here self-forgetfulness is anything but a privative condition, for it arises from devoting one's full attention to the matter at hand, and this is the spectator's own positive accomplishment" (Gadamer, Truth and method, p.126). "Our starting point is that verbally constituted experience of the world expresses not what is present-at-hand, that which is calculated or measured, but what exists, what man recognizes as existent and significant. The process of understanding practiced in the moral sciences can recognize itself in this--and not in the methodological ideal of rational construction that dominates modern mathematically based natural science" (p.456).

In those that Gadamer calls moral sciences, and others call human sciences, the truth is not a representation, a human construction that needs empirical validation through measures and controls. Truth here is not a construction, but the logos that unveils itself (in Greek: aletheia) to the extent that the subject is capable of self-forgetfulness. In human sciences the method is not that of measure and control, but just the opposite, of letting go of all attempt at dominating and controlling the object, in a discipline of self-forgetfulness. Paul is skeptical about the clinician's capacity of bracketing his or her biases. I am skeptical about his skepticism. If the clinician cannot overcome his or her biases, how can he or she possibly expect that his or her patient overcome theirs? How can a true dialogue ever develop with a clinician incapable of putting aside their prejudices, beliefs and theories, in order to truly listen to their patient?

For a true dialogue to happen, it is necessary for the clinician to be able to bracket as much as possible all their theories and beliefs. Of course, it can happen only to a limited extent. The clinicians operating in the dialogic paradigm are subject to self-deception as everybody else. But their way of combating self-deception is different. They don't use measures and controls, but discipline of self-forgetfulness and dialogue. I don't mean that every therapist should choose the dialogic paradigm. They should do so only if dialogue is at the core of their practice. Otherwise, if they feel at ease in a practice in which what counts is the administration of empirically supported procedures, the representational paradigm is their home base. Isn't it possible that we acknowledge and respect each other's paradigms?

Mike Basseches, March 29

Despite my awareness of the limitations of email, I would like to say first, in response to Tullio, that when I first learned the word "empirical", it was in the context of studying philosophy in 1968-70. I first understood it to represent an alternative to attempting to solve problems by reason alone. It represented the idea that we could turn to experience as a way of meaningfully answering questions. I think I agreed enough to become a psychologist, which I still understand as an empirical (experience-seeking) branch of philosophy. In those years, I also read W.V.O Quine's article, "two dogmas of empiricism", which distinguished learning from experience (empirical observation or study) from the belief system -- "empiricism" -- which claimed that systematic and carefully counted and recorded experience was both necessary and sufficient for achieving knowledge.

Quine demonstrated that any observation or empirical study had to be understood as a test of an entire knowledge structure, and could not be justifiably construed as a test of a single proposition or hypothesis. He argued essentially that experience that was discrepant from what one expected on the basis of humans' individual or shared reasoning, could be assimilated (to use a Piagetian term) by any of a considerable variety of adjustments in the frame of reasoning that generated the expectations. Thus reason must be engaged in the decision making regarding which adjustments to make within the interdependent knowledge structure.

So I think this leads to an understanding of "empirical" that is not that different from Paul's. But to address Tullio's comment, allow me to introduce my recent book with Mike Mascolo "Psychotherapy as a Developmental Process." In this book we describe in great detail what we consider to be a rigorous systematic empirical method for examining the dialogue that occurs within each single unique case of psychotherapy. I believe this method is no less empirical than research that takes many psychotherapy cases, extracts from all that material measures or choices of very particular input, process, and outcome variables, and discusses the relationship of the variables across the cases. Because our method focuses on tracking the particular developmental movement that is occurring in a particular case, or recognizing where the case is stuck, it is essentially a qualitative method, although there may also be quantitative questions that can be asked about changes over time within one case, or similarities and differences among cases.

Of course, it allows for any single case to become an empirically-supported-treatment, but since the treatment is not standardized, its relationship to other cases cannot be assumed, but becomes an interesting question to explore -- especially in a place like SEPI, where there is so much interest in how different approaches can be integrated.

In any case, back to Tullio's points, something like the "bracketing" of one's own perspective on the part of therapists is one important way of facilitating dialogue that leads to development. But a therapist articulating his or her perspective may at other times become equally important in facilitating such dialogue. And actively providing opportunities for clients to have novel experiences is another thing that therapists can do which at times fosters clients' development (and therapists' as well).

So to Tullio I say, I am happy to accept the value of attempts to "bracket", (I agree it can never be completely achieved), if you will also accept that there are other equally important ways to foster knowledge-constitutive dialogue. And with Tullio I accept the value of large N, quantitative studies, but I think that studies of individual cases can be just as rigorously done (and refer to our book for how). I also don't accept Tullio's view that all systematic experiencing or analysis of experience is done within a frame of "representational assumptions". One can assume not representation, but rather interaction (hopefully adaptive!) with the environment, as both the ground out of which humans create knowledge -- (understood as novel reorganization of individual and collective action). One can also assume that it is through further interaction, that knowledge both becomes "validated" and further modified.

I think what we are all searching for is some kind of adequate philosophical grounding for basing all our efforts to understand psychotherapy and psychotherapy integration, and I so appreciate all of the wrestling with these issues. I look forward to seeing those I will see in Seattle, those I will see in Florence, and someday those with whom for now our interaction remains in cyberspace.

Eleanor Webber, March 29

So much of the current approach to science, as applied to psychology, grows out of positivism, a movement which was originated by Auguste Comte, a man who had severe emotional difficulties. His idea was that you must be able to directly, through the five senses, observe what is being studied. This limited study to external observations and eliminated study of internal factors, which cannot be directly observed by the senses. This approach has the advantage of others being able to share the observation and, presumably, to replicate the experiment and again look at and determine if the observation can be repeated. Another very strong influence behind this method of scientific study was the belief that the methods of studying the physical world could be applied to studying people—with the assumption being that we are physical objects living in a physical world. Thus, we could be studied like chemicals or planets or rocks.

The problem is that so much about people cannot be studied in this way and that there are clearly aspects of human nature that do not lend themselves to this sort of objective observations. So the question is—or should be—do we then limit ourselves to studying what can be studied this way, or do we change our method of observation? The current paradigm chooses the first option. I choose the second. I made an attempt for years to try to understand the ‘new physics’, hoping that it would be more useful in understanding humans than trying to adapt the Newtonian paradigm has been. My conclusion is that it is not. Further, I had the opportunity to speak to a few physicists along the way and they all seemed amazed that psychologists would think that using their sort of approach would make sense in studying people.

I could go on and on about this as it has been a huge interest of mine throughout my career, but I will close with this comment-it is my guess that Comte tried to limit the study of humans in the way he did because it helped him shut down awareness of his turbulent inner world. I myself strongly agree with Jung that Americans are ‘extraverted as hell’ and are making the mistake of overvaluing the external world over the inner.

Dave Reiss, March 29

FWIW, years ago, when I was doing some work with Arnold Mandel ("MacArthur genius" award winner), he was working on modeling the action of psychotropic meds using stochastic rather than linear systems, and there was definitely a usefulness there beyond the current conceptualization of "neurotransmitters". I was working with him to integrate that into a model of psychopathology in general. It does not help to "understand people", but it was useful in understanding why psychopathology cannot be accurately assessed in a linear mode of thinking, and why therapies based on linear modes of thinking, whether somatic (meds) or psychotherapeutic were limited. It was useful in at least being able to model via diagram some pathological "cycles" and phenomena (beyond "bipolar cylces"). We never got to the point of trying to see if we could use that data to advance new specific practical applications, and i moved on, I don't know where Mandel went with it -- but I believe that an understanding of stochastic process is useful; just as an understanding of psychodynamics is useful to a therapist even in a patient who has no ability to participate in insight-oriented therapy.

Paul Wachtel, March 29

The complicated question about our mutual skepticisms is probably one for another discussion. To just slightly anticipate that discussion, I don't view us as helping the patient to clear himself of biases and preconceptions and see things simply "as they are" any more than I think we as clinicians or researchers can do that. But I don't think, in either case, that that simply dooms us to total illusion. But, again, that is a larger topic that I won't go into here (and am not sure I really have the philosophical competence to do it full justice).

But I do want to comment on what I think are two misunderstandings of my position in Tullio's post that I want to correct. (1) Tullio attributes to me the following,: Not all observation is empirical, clarifies Paul: just controlled That is a paraphrase, not a quote on his part, and it is a paraphrase that presents my meaning as essentially the opposite of what I said. My central point was that we should not limit the use of the term empirical to controlled studies, that this misleads as to what the meaning of empirical is, and that a variety of other methods are equally empirical, tho they may vary in how believable or trustworthy the reports are. (2) Tullio refers to objective truth and subjective contamination in a way that makes it seem that I have used these terms. I did not. There are a host of difficulties with the concept of "objective" truth, and I do not use the term. I believe that we can know something about reality -- I am not a radical postmodernist or relativist, and find the extreme versions even of constructivism (tho in certain respects I am a constructivist) to be unhelpful, seeming to imply that we can know nothing about reality and only about our biases and constructions. But however we might describe that being in touch with reality that I safely assume every time I try not to knock my head into a wall, I also know that, again, I do not know well enough how to play the "philosophy game" to state it in the most adequate way. So I just avoid words like "objective" and am uncomfortable when someone reads me as saying we should be aiming for objective truth.
On the other hand, I am equally uncomfortable with Tullio attributing to me the term "subjective contamination," which I also did not use. I talked about self-deception, but not subjective contamination. The difference is important, because the latter term seems to imply that we must eliminate any traces of the subjective, something that I most certainly do not very well at all without including one's subjective experience of the patient as part of one's "data base," as it were. Nor can we be socially appropriate or effective human beings without using our subjective experience, not only to understand what we are feeling but to get a better sense of what the other

I do not believe that this subjective experience is necessarily accurate, certainly not infallible. Not by a long shot! But it is nonetheless indispensable. We are stuck with this, so to speak, and also blessed by this. The combination means a lot of hard work, attending to our subjective experience and then reflecting on it, discussing it with others (yes, I too am a fan of dialogue). It means humility, a sense of perspective, but at the same time an affirmation of the value of subjectivity.

I'm sorry to be so long winded here. But my earlier (admittedly also long-winded) posting had the intention of clarifying ambiguities that lead us to disagree with phantoms rather than each other and to set up straw men to knock down. For that reason, I am very, very concerned about our quoting or paraphrasing each other in ways that address what we have actually said, not the conveniently slightly off center version of what we said that make arguments and refutations seem easier. So I wanted to clarify where Tullio's presentation of my views was actually not a presentation of my views.

I still, Tullio, am eager to continue our dialogue, and as I have said on many previous occasions, that works better over a cappuccino than over the internet. Then we can clarify what feels like a misrepresentation, move on to discussion, and avoid having it sound so much like a rebuke when it is part of the very nature of discussion. So I am looking forward to Florence, and to the continuation of the dialogue. person is feeling. I have emphasized this in my most recent book, Relational Theory and the Practice of Psychotherapy.

Mike Basseches, March 29

Yes, Paul, with your clarification I am even clearer in my sense that we by and large agree, and I think I was made uncertain by how Tullio represented your view. I think that the dichotomy between objectivity and subjectivity completely breaks down when we acknowledge that we are constantly in interaction among each other and with our material environment. Both are mythical ideals. We cannot achieve objectivity, but through the dialectical construction of increased intersubjectivity, and through the seeking equilibrium in our dynamic interactions with the environment, we can increase the adequacy of our knowledge.

David Allen, March 29

I am also glad that Paul clarified what he said in re Tullio's characterization, and I like what Paul said and Michael's comment.

Although I am certainly capable of doing so, I try not to get too esoteric about discussing these sorts of issues, because it can lead to obfuscation rather than clarity. I try to be more pragmatic. We really don't have to completely understand the true nature of reality vis-a-vis our mental construction thereof to determine what data is valid and what is not.

In a way it amazes me that we still have to debate whether internal processes can be studied using quantitative rather than qualitative measures like the behaviorists of old. On the other hand, I think treating patients with the Bion-ic "no memory and no desire" is an absurdity.

Just because some clinical observations and reports are heavily biased does not mean that they all are. Sheesh, and we accuse our borderline patients of splitting! Yes, of course we can not completely eliminate subjectivity, but the good news is, we don't have to. I understand that we can never truly "know" the concrete wall that's next to the lane on the road that we are driving on - we can only "construct" a mental model, or schema if you will, of the wall. Still, we can drive 100 miles per hour right next to it without hitting it, so I have to say our mental model must be pretty darn good.

Our mental schemas of other individuals suffer from a similar limitation. However, if you've been living with people for a few years, you don't wake up to strangers every morning. Despite their reputation for distorting (which they only do if you ask for judgments rather than actual descriptions of other people's behavior), I find my borderline patients are fantastic at predicting their family members' responses to specific verbal interventions I demonstrate in role playing. The only time they are stumped, understandably, is when I suggest something completely novel to the entire family.

Tullio Carere, March 29

Paul, I am very sorry that I misrepresented your positions in my last post. On the other hand, this is what happens all the time: mutual misrepresentation is the inevitable toll we must pay just to have access to dialogue. Dialogue itself is, in my view, the remedy to this inevitable misunderstanding, provided that we really want to get at least at an acceptable level of mutual understanding. This brings us directly to the first topic, that of mutual skepticism. I know that you are "a fan of dialogue", no less than me. This is why I am skeptic when I read you saying that you are skeptic about the possibility of bracketing our biases. What kind of dialogue can ever happen, if we are not both capable of and willing to discipline ourselves in the practice of suspending all the preconceptions and expectations that we consciously bring into the dialogue, plus those that come up in the course of the exchange? Let me make it clear. I call true or authentic dialogue the one that I have just defined, and false dialogue the one in which one engages without the honest and sincere intention to put at stake one's most cherished beliefs. In other words, true dialogue is not for believers, not even for believers in empirical science. As I am sure that you are not a believer, I am skeptical when I hear you say that you are skeptical about the very premise of true dialogue.

Coming to the misunderstandings:

I attributed to you the following: "Not all observation is empirical, clarifies Paul: just controlled observation". It is a paraphrase, right, not a quote. Here are the quotes, from your post of March 26 (bolds mine): "What I mean is that formulating one's theories or one's ideas about a case formulation on the basis of clinical impressions is as 'empirical' as doing an experiment. Both rely on 'what we see.' The problems arise in interpreting what we see, in knowing how, whether, or in what way to trust what we see. What is usually meant when the word 'empirical' is used is really something like controlled observations." I understand, from this passage, that you say: clinical impressions can be as good as experiments for an empirical approach: empirical does not mean experimental, but just controlled observation. My understanding is reinforced by what follows: "The various methods of science -- experimental controls, double-blind evaluations, systematic correlations rather than 'it looks like the more of this the more of that,' etc are all ways to address this tendency [i.e., to self-deception]. In a different way, the non-quantitative configurational methods of, say, historians or literary critics are a similar kind of effort....These methods are not perfect (neither are those we call 'scientific'), but like the methods of science they help to control for seeing just what we want to see, they are ways of weighing the evidence." It seems clear to me that controlled observation is what you suggest to neutralize the tendency to self-deception: not just in what we call 'scientific', but also in history or literary critics. You don't refer here to controlled studies, but more in general to a sound attitude of "weighing the evidence". In your words, a method is empirical to the extent that it controls its evidence, not necessarily through experimental or quantitative tools. In conclusion, it seems to me that my paraphrase concentrated in few words what I have quoted now extensively. I really can't see where I can have betrayed your thought.
Then you write: "Tullio refers to objective truth and subjective contamination in a way that makes it seem that I have used these terms. I did not." Right, you didn't. It's again a paraphrase. Firstly, I surely did not mean with the expression "subjective contamination" that you believe that any subjective experience is a contamination! How could I have ever meant such a nonsense? Not even the most organicist psychiatrist believes that. It should be obvious that by "subjective contamination" I meant the component in the subjective experience that is due to self-deception, in line with what you said before. I wrote: "The various methods of science listed by Paul -- experimental controls, double-blind evaluations, systematic correlations, audio and video-recording of the sessions -- have all the same task: to neutralize as much as possible all subjective bias (our ways of deceiving ourselves) in order to approximate as much as possible objective truth." So much for the "subjective" part of the misunderstanding. As for the "objective" part, it is true that you didn't use that word. But it seems to me that the subjective experience happening in the dialogue is not enough for you: not enough to conveniently neutralize the tendency to self-deception. You seem to need something more, something "objective" like the disc on which you have recorded your sessions. A disc or a transcript is an object with which you can do many things. It is permanently there, you can return to it many times, you can show it to others, you can break it down in many sequences that you can code and count... This may explain my reference to objective truth. Anyway, I am ready to correct myself on this point. I might have attributed to you a position in favor of objective truth firstly because it is the usual position in empirical science, secondly because I am not sure to understand what is your idea of truth, given that it is not the one commonly endorsed in empirical science. I am sure that this misunderstanding will be completely dissipated when I shall be able to understand what you mean by truth. In your last book there are a couple of references to the true self, but not a single one to the concept or the experience of truth. Just to say that I hope I may be forgiven for misrepresenting your idea of truth.

I, too, Paul, am eager to continue our dialogue. Over a cappuccino -- or even better, a glass of Chianti -- in Florence next year, but possibly also on the internet, which sometimes is even better than the cappuccino or the glass of Chianti for firstly creating, and then overcoming, misunderstandings.

Paul Wachtel, March 29

Hi Tullio,

I see now the source of your misunderstanding of what I intended. I did say, "What is usually meant when the word 'empirical' is used is really something like controlled observations," as you quote. But I was referring to how people (even in our listserve exchange) often, maybe even usually use the term. But my own intent in my message was to challenge how the term is usually used, which is what the sentences you quote just before this do.

You also paraphrase me as saying,"In your words, a method is empirical to the extent that it controls its evidence." I did not say that. I'd say that my trust in the conclusions offer would correlate with that, but not my decision as to whether it is "empirical." These confusions are the very reason I am inclined to retire the word empirical altogether in much of these discussions, tho it has a good deal of relevance and meaning in distinction with, say, theoretical inquiry. I value the latter as well (it is a lot of what I do). I agree with those who point out that the distinction is not absolute -- that our "empirical" observations are quite theory-laden (which is why I am so skeptical of your and Bion's contentions); and also that good theory is theory that has empirical implications rather than being just word-play. But I still view empirical research as something other than theoretical inquiry, at least on a continuum. But lest this too be misunderstood, it does not mean that I view clinical observation, or observations from everyday life as any less "empirical" than controlled experiments. Just as more likely to be vulnerable to a higher degree of not even taking into account how impossible it is to "bracket" our biases. Again, it's not an absolute. There are savvy and careful clinical observers who observe with an eye toward how can I check on my observations and there are sloppy experimenters who just go thru the motions but don't really exercise care or thought. But in general, one is a mode of observation with more safeguards than the other.

So now, my question is, am I similarly misunderstanding you when I read the following passage as imply that we are capable of completely and totally able to put our biases and preconceptions aside? I am responding to the word "all":

What kind of dialogue can ever happen, if we are not both capable of and willing to discipline ourselves in the practice of suspending all the preconceptions and expectations that we consciously bring into the dialogue, plus those that come up in the course of the exchange?

I don't think that is even remotely possible. If I thought that was necessary to have a meaningful dialogue, I would despair of the possibility of having a meaningful dialogue. But I don't think anything even approaching this God-like capacity is necessary to have a dialogue with someone who has a sincere desire to listen and exchange views. I view you as such a person, so I am still looking forward to our own dialogue in Florence. And I like your amendment of trying to find the veritas in vino. Whether we find the veritas or not, we'll probably enjoy it more than just typing on the internet.

Tullio Carere, March 29

Hi Mike. Commenting my last post, you wrote:

There is a big misunderstanding around the theme of bracketing one's own perspective, together with all preconceptions and expectations, as much as one can (no one has God's eye). It is most often dismissed as mere nonsense, people make jokes about immaculate perception, and similar pleasantry. Bracketing does not mean canceling. Freedom from memory and desire does not mean annihilation of memory and desire. It just means to be free, i.e. not conditioned by one's memory and desire (again: as much free as possible, there is nothing like absolute freedom). If I am free from my own theories (to the extent that I am free), it means that at any given moment I am free to observe whatever is not foreseen by them, but I am also free to use them, in case their use appears useful in the case at hand. In the interaction with my patient I can use my theories, her theories, the theory that I or she create from scratch in the moment, or no theory at all. If I am not driven by anything known or any expectation, it does not prevent me to use anything from my archive: the point is that I am the driver, not my theory or anybody's else theory. More precisely, I am not the driver, and neither my patient is: the process is the driver. The process suggests all the time what to do in order to break old schemes, open up to new insights and novel experiences. If we listen to its voice, we learn to flow with the process, letting go of our pretence to direct it where our theories or our expectations want it to go.

Don't listen to me, listen to the logos, warned Eraclitus, and you will learn that all is one (i.e., you will be free of the illusion of subject and object being two separate entities). But it is not easy to listen to the process, or the logos. One must learn to be silent inside, otherwise the noise of all the thoughts conditioned by memory and desire will cover up entirely the subtle voice of the logos. And one must learn to trust the process -- this is what Bion called Faith in O. He also warned that letting go of all security grounded in familiar schemes may amount to a catastrophic experience that could be impossible to face, unless a strong enough confidence in the unknown is established.

Then you wrote:

And with Tullio I accept the value of large N, quantitative studies, but I think that studies of individual cases can be just as rigorously done (and refer to our book for how). I also don't accept Tullio's view that all systematic experiencing or analysis of experience is done within a frame of "representational assumptions". One can assume not representation, but rather interaction (hopefully adaptive!) with the environment, as both the ground out of which humans create knowledge -- (understood as novel reorganization of individual and collective action). One can also assume that it is through further interaction, that knowledge both becomes "validated" and further modified.

Let us say that the interaction is the real thing, the Ding an sich -- maybe you call interaction what I call the process, but interaction is fine to me. How do you relate to it? If you relate to it through your representations, i.e. your mental constructions, you are still inside the representational paradigm. If you can enter the interaction with an empty mind, open to all clues coming from everywhere (your archive of theories and techniques included, provided that the interaction is not guided by any archive), ready to follow the guide of the process, then you enter a true dialogue: the name that the interaction deserves when it is not a manipulation of the other to whatever goal (beware of ideal goals), nor it is a negotiation to arrive at any reasonable compromise, but is the process that happens when it can develop according to its own inner logic: and this can happen when the persons involved in the interaction accept to bracket their own personal agendas for the sake of a logic -- of a truth -- that goes beyond them.

Can you agree with my idea of truth? If not, which is yours?

Tullio Carere, March 30

Hi Paul,

climbing high mountains is the extreme challenge to some. The one I prefer is dialogue. Jaspers, one of my masters, observed that in spite of our best intentions we arrive at points ("Grenzsituationen") where communication seems to be impossible. At these points he found, like Bion, that one needs faith for not to be daunted: philosophical faith, as he called it to distinguish it from religious faith. Philosophical faith supports me in following Serge Prengel's suggestion to "explore ways to try to consciously address the inevitable misunderstandings and misconceptions; [and] make dealing with them part of the discussion process itself".

You say that your intent was to challenge how the term control is used: this, you say, was the source of my misunderstanding. I had considered this possibility after your previous message, but had discarded it for two reasons. The first was the comparison with the couple of sentences that follow in which the word control is used with no evidence of challenge, to my eyes. The second, and more important, is that if the term control is challenged, and not used to denote a type of observation ("controlled") different from ordinary observation, then I fail to understand the gist of your argument. If observation should not be "controlled" (through audio and video taping, as I wrongly understood), then what is that makes it different from the ordinary observation, ordinarily biased by our "prodigious capacity for self-deception"? Given that you are "inclined to retire the word empirical altogether", challenge the word control, and obviously don't consider the discipline of self-forgetfulness that Gadamer recommends for human sciences, then what remains to distinguish ordinary observation from the one that more or less deserves to be called scientific?

Finally you ask:

The word "all" applies to the willingness to put aside all our biases and preconceptions, without exclusion -- that is our most cherished beliefs included. I don't understand how this willingness can be understood as a complete and total capacity, given that in the previous message of the same day I had been careful to write: "For a true dialogue to happen, it is necessary for the clinician to be able to bracket as much as possible all their theories and beliefs. Of course, it can happen only to a limited extent."

Paul, even in the hardness of this exchange, I don't forget that our dialogue happens in a space that would not exist without your founding and continuous, generous supporting of an association that I have come to feel as my scientific home base.

Tullio Carere, March 30

Good morning Paolo. Let us start a new round of our yearlong conversation, while our American friends are still sleeping. You ask: "You say that the therapist should bracket his own biases, but what is the method (empirical or else) you use to establish that he does so?". Firstly, I ask: are you willing to bracket all your presuppositions and expectations, all your theories and beliefs, as much as you possibly can, for the sake of dialogue? The reply I get is usually: no, I can't, I don't even believe that it is possible. Take Paul's response: "I don't think that is even remotely possible." Part of the problem arises from a misunderstanding. Although I keep repeating that the practice of putting aside memory and desire is in fact a practice, a discipline, not an accomplishment, people regularly understand me as though I were asking them a God-like performance. It is not. It is a discipline that in different forms has been practiced in many cultures in all times. Take the Buddhists, for example: their practices of meditation point to the empty mind -- that is, a mind that is as empty as possible: no memory, no desire, just the awareness of the present moment. Every experienced meditator can bear witness of the existence of a state of consciousness that is silent, peaceful, conflict-free (even ego psychology has the notion of a conflict-free ground of the mind). Of course, you must train your mind if you want to realize this state of consciousness. It does not come by itself.

You could object that even Buddhists have their theories and beliefs that they never give up. In many cases this is true, but not in all. There are Buddhists who use their theories and techniques as I do with mine: like tools that can be used when they are useful, and put aside when they are not, in total freedom. I also know of Christians who can bracket all dogmas and beliefs of their church for the sake of true dialogue. They are angry with their pope, who instead sticks firmly with his eternal truths. Yet I appreciate the honesty of this pope, who unambiguously states that he does not believe in interreligious dialogue. He cannot give up his dogmas: if he did, he would immediately fall down his cathedra. This is the same for the majority of our colleagues, as I see them. They are identified with their theories. There are psychoanalysts who would be lost, if they could no longer identify themselves as psychoanalysts. If the very foundation of your identity vacillates, it can be an appalling experience, really intolerable for many. As I wrote in my response to Mike, you must have developed a strong enough confidence in the unknown, for letting go of all that is known. You must have had at least a glimpse of the fact that the unknown, for appalling that it is, also is the source of a generative and healing power. You must be at least a little familiar with the process of symbolic death and rebirth, that is the key feature of many paths of knowledge, since the shamans (you know that Bion was called a shaman, often, but not always, in a derogatory meaning).

To summarize, many say that it is impossible to put aside one's biases because of a misunderstanding: they believe that what they are called to is an accomplishment, instead of just a discipline, that one can practice as good as one can. Secondly, many refuse to engage in such a discipline because their identity depends on their theories and beliefs, and have not (yet) seen the possibility of grounding it on the unknown, instead of the known. But for doing so, one must have the temperament of a mystic, which most have not. Then, you may ask me: why do you go on trying to dialogue with me (Paolo), and many others like me, knowing very well that we are not mystics? Maybe because I try to wake up the mystic in you. I, like Bion, am persuaded that the analyst must be both a scientist and a mystic. Too much science brings to rationalism, too much mysticism leads to irrationalism. Both sides are necessary, in my view, for a good dialogue. And, I would add, for a good life.

Paolo Migone, March 30

Dear Tullio,

thank you for your generous reply, I see that the difference of opinion between us is still alive and well, and of course I will not discuss it here since we did it many times, and I do not want to bore our US friends.

I have the impression, though, that you did not reply to my question. I repeat it: what is the method (empirical or else) you use to establish that one brackets his own biases or that he does not do it.

Tyler Carpenter, March 30

Who's asleep, Tullio?!

I suspect that we are all closer than we might think. At it's heart and stripped down to the basics, the process you describe is well known for millennia: following the breath and watching how the process of thought moves to create the illusion that is reality. The solutions for us may end up being a variant of what those committed to the meditative disciplines have developed for years (quite heterogeneous in some respects, but basic in others). Since at least when Jung wrote the introduction to Evans-Wentz' translation of the Tibetan Book of the Dead (Tim Leary, Richard Alpert, and Ralph Meltzer did an annotated version for guiding initiates through LSD trips-see www.sacred-texts.com/budtib/psydead.htm), psychologists have had an interest in what is essentially the ground of meditation. The late Thomas Merton when he died and psychoanalyst-Renaissance Man Gregory Zilboorg shared an interest in contemplative practice, psychoanalysts and now CBTers revisit zen every 10 or so years, The MindLife Institute is currently organizing yearly retreats for all kinds of scientists, B. Alan Wallace, Ph.D writes prolifically on integrating meditative philosophy and science as does University of Colorado Emeritus Professor of Neurology James H. Austin on zen and neuroscience.

Does SEPI have a Buddha nature? And, if you see someone who has one walking on the virtual road, kill him (or her) virtually of course!.

Thoughts with no thinker is the putative goal!

Jason Hutchings, March 30

Hi Tullio and Paolo,

My name is Jason Hutchings, I am new to the list serve. Seems like quite the lively discussion!
Paolo: I think what Tullio might be trying to say is that we need to practice being aware of our biases, beliefs, mechanical attitudes, thoughts and emotional reactions. Essentially the more modern take on countertransference (That reactions are not just neurotic hangups but rather can be useful information IF WE ARE AWARE OF IT, this includes emotions, thoughts and physical reactions like tension) . If we are reacting from habit (scientific theory or otherwise), we are doing a disservice by not consciously processing the patients needs.
As to how we do this: What Tullio wrote about Mysticism and Science has great appeal to me. I practice meditation daily and find the results very helpful in the therapy hour. If one is not drawn to one of the contemplative traditions or does not resonate with the language, and does not feel the drive to practice on their own, simply understanding, reading books like Krishnamurti's Freedom From the Known, Zen mind beginners mind and others will give a broader perspective. I know it is a cyclical problem, but dont many psychotherapists themselves go to therapy so as to be more aware of what they are thinking and feeling and so it does not skew their clinical judgement? Although I may not have been clear and we are all destine to misunderstand each other at points, I am glad these discussions exist.

Paolo Migone, March 30

Thank you, Jason, and welcome to the list. I strongly doubt that all Tullio wants is to restate the usefulness of countertransference in its "totalistic" view (i.e., in the enlarged sense). Did he suddenly discover something that is fashionable today in psychoanalysis? The use of countertransference in its wider sense is being discussed since about four decades (and in the non-official literature since the 1920s). I think Tullio is more ambitious than that.

David Allen, March 30

Tullio,

If by bracketing you mean being open to information that calls our pet psychotherapy theories (or our hypotheses about a particular patient) into question, and not ignoring it, dismissing it, explaining it away, or in other ways deceiving ourselves about it, then you and I are in complete agreement. Hopefully, that’s why SEPI exists, because for too long the gurus of various therapy paradigms have ignored or summarily dismissed the observations of therapists from other schools.

If on the other hand, you’re talking about the therapist using a Zen-like state of mind as the predominant therapeutic technique, then I have to disagree with you. I hope I will always have a strong desire for my patients to lead a happier and more satisfying existence, and constantly remember the blocks to that goal that we have identified, as well as what has and has not worked for them in the past, so they don’t keep making the same mistakes over and over again.

Maybe it’s just the M.D in me, but at least in my opinion, therapy (especially if it is paid for by medical insurance) should be a treatment for something, not just a vehicle for personal growth (and it doesn’t have to be treatment for a mental “disease” but can also be a treatment for chronic repetitive dysfunctional behavior or pervasive unhappiness/anxiety). It’s precisely the open-ended, almost behavioral-goal-free type of therapy that managed care companies in the US have seized upon to devalue what therapists do and ratchet down fees to the point where they are in no way comparable to those of professions with similar educational and skill requirements. I am concerned that some of us may unwittingly be continuing to provide them with more ammunition to use against us.

As an aside, I do not believe that self-deception is a passive, completely unconscious process as some analysts do, but an active process that requires mental energy. Is the housewife who has been washing the lipstick off her husband’s collars when doing his laundry over many months really “surprised” when finally confronted with irrefutable proof that he is having an affair? She may tell herself she is, and she may have tried very hard not to think about the lipstick, but I submit that she had to have seen it, and on some level been aware of its implications.

Tyler Carpenter, March 30

I doubt anyone, especially an MD, would consider the concrete benefits of lower basal metabolism, lower resting heart rate (not in psychopaths), increased alpha wave activity, anything but beneficial to patients' well-being, David. The metapsychology of the process is an interesting discussion as well. What the insurance companies were beefing about was the neglect of the seriously and chronically mentally ill and the disproportionate share of the insurance dollar going to the least severely ill (though now it would appear to go to the execs and that worries others). My experience in public health suggests that that is a problem that has not changed a heck of a lot. The issue of subjectivity and the role and relationship of insight to meaningful and symptom free function is a vast and important one that likely lies on a continuum with navel gazing and iatrogenesis as anchor points.

David Allen, March 30

Tyler,

Naval gazing and iatrogenesis! A great line! I have been in psychiatry since I started residency in 1974. I used to see far too much of the former, while now I see far too much of the latter. Lately everyone and their brother-in-law is being diagnosed with the phony “Bipolar II” disorder and put on inappropriate medications that make them fat, diabetic, and/or mentally cloudy. And don’t get me started on how the clueless parents of acting-out children and adolescents are being told that their kids have all sorts of “organic” brain disorders (as if normal brain functioning is not organic).

I think you are giving the insurance companies way too much credit. IMO, they don’t care about the chronically mentally ill at all. I specialize in the treatment of borderline personality disorder (even though I don’t believe it’s a disease), and I think you would agree that these patients have severe problems and are just as worthy of treatment as chronic schizophrenics. I recently re-started private office practice one day a week after having been away from it for 17 years. Managed care has ratcheted the fees down so much that, if I did nothing but psychotherapy, I would barely be able to pay my office overhead and my malpractice insurance, let alone make a decent living.

The concrete benefits of Zen-like mental states that you mention below are great while they last, but at least with my patients, they would all evaporate the second they left my office and stepped back in to their chaotic relationships.

Christopher Stevens, March 30

Really? (about the evaporation). I'm late joining this conversation, so perhaps I've missed something essential. Nevertheless, using mindfulness as a component to treatment (with a powerful impact on affect regulation and distress tolerance) has been a very effective way to work with clients who fit a borderline diagnosis. I'm surprised to hear you say that it would not be effective with your clients. Of course developing effective mindfulness is a practice, a way of being, rather than a state (like relaxation) that can be induced and then 'lost'.

Tyler Carpenter, March 30

We appear to be roughly contemporaneous and share many of the same views and goals, it would appear, David. I tend to agree that bureaucracies and in particularly for profit (though not for profits with out size executive salaries pose an interesting econo-philosophical question) bureaucracies are not based on feelings, but economic bottom line and chronic illness is that bottom line. The coordinated use of partial hospital, day programs, self-help and other modalities in an integrated and multi-disciplinary manner represents if done well, a check against chronicity, morbidity, and iatrogenesis. This will not happen by psychologists opting out and Masters clinicians being shoehorned in, except in the case of what I guess is a limited proportion of the cases. I too tended to specialize in character disorders of a gamey sort and while I agree that they are not always psychotic (though Jack Engler wrote a nice paper on one way of conceptualizing how such regressions occur when Borderlines meditate), they represent precisely the challenges for which anything less than integrative treatment is doomed to fail in any one of a number of ways. I agree regarding the sad misuse of treatment and think that like geriatric patients we used to "detox" from the nursing home in the 70s, it would be therapeutic in many cases to clean them out and start over with a more comprehensive approach to treatment. To return to what I took to be central to Tullio and Paul's point about bracketing views and the impossibility of doing so systematically and reliably, that trying to maintain a value free and objective intrapsychic and bipersonal space is not only impossible, but not easily defined as the therapist's countertransference. My purpose in introducing the recursive and recurrent concept of a type of awareness associated with meditative disciplines, is not to define what it is and how to achieve it (zen is famous for labelling such efforts for what they are), but to suggest that whatever we do and what we enlist or use on what and why when we do so, would appear to benefit from just such an active, but undefinable process such as Tullio and Paul are attempting to define.

David Allen, March 30

Hi Christopher, thanks for your comment.

I totally agree that mindfulness techniques can help many patients with BPD tolerate distress better. So can the right medications properly prescribed (using the applicable psychotherapy techniques), which I find take much less time to work that teaching mindfulness skills. As to the latter, I usually just hand out to my patients a copy of the distress tolerance skill exercises from Marsha Linehan's Skills Training Manual, which is allowable under her copyright rules. My patients have often already tried many of the techniques, but they can definitely help. Many patients can employ them without attending a skills training group.

However, when their family dysfunction rises beyond a certain point, in my experience, neither meds nor mindfulness techniques stand a chance of keeping the patient calm and preventing them from acting out. Besides, for me calming them down is only the first stage of therapy. If someone is following you around constantly stabbing you in the shoulder with a pen knife, I can give you opiates so you can tolerate the situation with more equanimity. Wouldn't it be better, though, for me to stop the person with the knife from stabbing you? Living in the type of invalidating, sometimes abusive dysfunctional environment that characterizes the families of patients with BPD is like being constantly stabbed in the back. And of course, I am not forgetting that BPD patients give out as well as they get.

There's a lot of research coming out verifying that early fear tracks in the amygdala are extremely resistant to extinction by the usual process of neural plasticity. In fact, many neuroscientists believe you can not get rid of them at all, but you can only override them. In my clinical experience, borderline schemas based on these tracts are most powerfully reinforced by early attachment figures. As a therapist, I found that I was no match for the family of origin at all. I also found out that patients won't tell you what's really going on in detail unless you know how to ask. My treatment is based on ways to teach the patients how to get past their parents' formidable defenses and to metacommunicate about the family dynamics and the reasons they developed, so that the reinforcement patterns can be stopped.

Tyler Carpenter, March 31

On reflection, I would suggest that the conclusion of my response contains a bit of practical mysticism, but that sounds a little oxymoronic. On the other hand, the ever practical roshi would advise the initiate to wash his bowl when he finishes eating. And so, perhaps however impossible and debatable the contours of the observational process (consistently across the millennia), reflecting on how and why we see what we see is both an irreducible and intrinsic part of therapy whatever we are inclined to think its essential elements are?!

Tullio Carere, March 31

Paolo Migone wrote:

I have the impression, though, that you did not reply to my question. I repeat it: what is the method (empirical or else) you use to establish that one brackets his own biases or that he does not do it.

Hi Paolo, in my previous reply you find the first part of my answer to your question. I simply ask, in the first place, if one is willing to put aside or at stake (you cannot put at stake what you cannot put aside) all of one's preconceptions and beliefs to the best of one's good will. If they answer that they are not willing, or they don't believe that it is possible, well, you can believe them. If the answer is yes, you know that they are at least willing to do what you ask, though you don't know if they will really do what they will. This is the theoretical part of the question, the first part of my answer.

Then comes the practical side. Maybe a good dialogue can take place in spite of unfavorable theoretical premises, or viceversa: who knows? Of course, in case of unfavorable theoretical premises I give it a try only for a good enough reason. I would not lose my time trying to dialogue with a man idelogically blinded to the point to declare that the condom is useless to prevent AIDS. But I am surely willing to try with anybody in a forum like this (it is not very likely that pope Benedictus will ever subscribe to this forum). The practical method consists in trying to extract from the speech of the other his or her preconceptions or beliefs, in feeding them back in paraphrases or in quotes, and seeing if the other is willing firstly to own, and secondly to question, their beliefs, in the form I have understood them, or else to differently formulate them in their own words. When I do so (I don't do so very often) what usually happens is that the other gets soon annoyed. My reading of this interesting phenomenon is that generally believers are not happy when their beliefs are pinpointed. They mostly prefer to believe that their beliefs are not their beliefs, but just sound observation and reasoning.

I don't draw from such failures, though, the conclusion that I am the dialoguing person and the other is not. I limit myself to the observation that, one more time, what I call true dialogue does not happen when the willingness to put aside beliefs and expectations is low or absent. I unconditionally respect the right for the others to have their own versions of dialogue, provided that they don't try to impose them to me. Most of the times what is realistically possible is just one of these limited forms of dialogue, that I don't call true because the question of truth simply does not obtain here. In fact, what happens in these forms of dialogue would be true only if their unquestioned premises were true -- but, the premises being unquestioned, these forms of dialogue are neither true nor untrue: truth is just out of question.

Michael Kilpatrick, March 31

I'm new to your group, but not to the perceived dichotomy between objectivity and subjectivity. The views being expressed today are not to dissimilar to those expressed some 2,500 years before by Plato and Gorgias circa 400 BCE.

You might find the following excerpt (from Chapter 2) amusing, since it tries to get inside the mind of genius level intellect on this topic. Coincidentally Chapter 5 will address the genius level dialectic involving SEPI a one half of another dyad.

This dialectic between thes two many years ago epitomes the dialectic between the rationalizing hard sciences and perhaps the psycho-therapeutic sciences

Plato:

“... Although a negotiated perspective among points of view individuals must overcome their subjective biases to understand the objective reality of their task. This objectivity is a strict requirement of each individual’s capacity to realize the truth. Their subjectivity describes only the temporal chaos of their mind’s ambivalence in the process of realizing truth.”

Gaea (an intermediary character tries to mediate between the two perspectives):

“Enough is enough”, interrupts Gaea, “Time is in too short supply for us elders to listen to more of this mind-numbing tripe. The two of you have more important ...

"...Subjectivity is not the problem Plato, nor is objectivity your enemy Gorgias. Both are in fact inherent attributes of human nature. Objectivity and subjectivity are siblings born of the same heritage. Subjectivity’s perceived arbitrary randomness balances objectivity’s structured orderliness. Both are required for intellection but for different yet complementary purposes. The subjective assessment our preconscious mind's aesthetic symmetries and dissonances provide a foundation for our conscious assessment of their objective similarities and differences. For you Gorgias, subjectivity is an essential requisite for humanities power of imagination and your 'kairotic'moment of apperception. For you Plato objectivity is a balancing response to the arbitrary chaos our minds are capable of imagining. Thus its better you both learn to live with human nature, working together in tandem, rather than argue against each other’s perspective."

...Gorgias suggests to Gaea, “While there is mutuality to our subjective and objective natures, our archetypal memories or our mind’s salient biases stemming from this inherent subjectivity might also give rise to false concordances and judgmental error. Without belaboring the point Gaea, the question becomes how Plato and I must address the various types of biases of both our intuitive and rational minds. But perhaps this is a discussion to be left for another day.”

Fuel to fire, or a way forward?

Leslie Phelps, March 31

I am also new to this listserv and am impressed by the postings—is it always this lively?

Anyway, I have just finished reading On being certain, written by Robert Burton, a neurologist; and I think it applies to this discussion. I will do my best to reduce the book to a short paragraph. He proposes that the feeling of knowing or being certain is a mental sensation (not a thought or a feeling). We sometimes think we are deciding to accept “truths” based on our experience, but we are actually just experiencing the sensation of knowing. And, as with other perceptual sensations, this mental sensation is subject to perceptual illusions. Thus, even when we find evidence that our beliefs might be wrong, our experience of knowing can override that contrary evidence, leaving us not to trust it. Also, the sense of knowing feels so real that it’s insidious; we might not recognize it as anything less than a truth. What science teaches us is that we do not know things for certain; our “truths” are more accurately described as probabilities. By accepting this and reminding ourselves of it, we can choose to question our beliefs, even when we “know” they are right. Dr. Burton was not talking about therapy, but clearly his insights apply to therapy and to the discussion that has been going on here.

From the perspective taken by Dr. Burton, we would do well to try to “bracket” our biases, but that does not guarantee that we will do it or even recognize our biases (even with years of developing that skill). So, the best we can do (and what we must do) is constantly question our perceptions and beliefs, especially when we are convinced of what we “know.” In this way, even when we do not see our biases in a given moment, we are working to remain open to them. Seeing our biases is a process that we can improve with effort and training, but it is not a skill that is accomplished. I also believe that our efforts at “bracketing” our biases are best when we share our thoughts openly with others—the more honest, open, and deep the dialogue, the more insightful we will be both in and out of sessions. And, to Dr. Burton’s point, I could have stated the previous sentence without “I also believe that…”, but that would have made a statement of certainty and we all benefit from acknowledging that we are less than certain. He states (p. 218), "The message at the heart of this book is that the feelings of knowing, correctness conviction, and certainty aren't deliberate conclusions and conscious choices. They are mental sensations that happen to us...We laugh at a magic trick...We cannot train ourselves to see the sleight of hand that makes it impossible to win at three-card monte, but we can tell ourselves that we are being deceived and not to trust what we see. Let this be the model for the feeling of knowing. Neuroscience needs to address the physiology; we need to question the feeling. And nothing could be more basic than to simply question the phrase, 'I know.'"

Tyler Carpenter, March 31

Welcome to the list, Leslie. Great reference! Slife in his chapter on epistemological challenges to models of psychotherapy, in the current incarnation of Garfield and Bergin's great text on psychotherapy and behavior change, similarly urges us to continuously examine our assumptions and adopt a pragmatically informed and eclectic approach the philosophical underpinnings of our craft and art.

David Allen, March 31

Excellent points all, and I agree that we should constantly be questioning what we think we know (sort of the basis of Acceptance and Commitment Therapy).

Just to be devil’s advocate for a moment, however, one can take this line of thinking a bit too far. Facts are facts, and there are many that we can be absolutely certain of, unless reality is a complete figment of our imaginations. For example, as a physician, I have personally witnessed patients die. I am absolutely certain that they are, in fact, dead. And I have pretty good reason to believe that they will remain so, even though that is an inductive conclusion.

Inductive conclusions are interesting, but they can never be proved. Let’s see. I am holding a pen in my hand about four feet from the floor. I feel absolutely certain that when I let go of it, it will fall to the floor. Well, I’ll be darned, it did it again!

Luca Panseri, March 31

Thank you Leslie, I really appreciated what you wrote.

This can be very helpful as a reminder when we get caught by the illusion that we can be certain about something. It requires ( at least to me) great personal effort to remain aware and humble, or regain awareness when it gets lost, about the fact that, ultimately, we know nothing for sure.

Said that, I feel very close to Tullio’s proposal to bracket as much as possible all theories and beliefs and to you when you write that “ our efforts at “bracketing” our biases are best when we share our thoughts openly with others—the more honest, open, and deep the dialogue, the more insightful we will be both in and out of sessions”.

I have personally experienced that the meditative practice (for example Vipassana meditation) and genuine dialogue are both helpful to get some freedom from my tendency to take my thoughts, emotions and body sensations as the “reality” and to build on them my theories and “certainties”.

Leslie Phelps, March 31

David,

Fair enough. But in some time from now, will you remember whether you really dropped your pen to prove your point or whether you just thought of doing it? And, how sure will you be of that answer? -- and, will you be right?

All joking aside, as I'm sure you know, empirical research (what is that, again?) has shown that we often misremember even simple things, and are sure of our memory. So, while I agree with you, I think we still need to be careful of relying on our memories -- which, when challenged, can leave us feeling like things are being taken too far, since we are often so sure of what we remember. In fact, in the book that I referenced, Burton described one study that I found interesting. A day after the space shuttle the Challenger exploded, students were asked to write about the circumstances in which they heard about it. Two and half years later, these students were asked the same question, and 25% of them answered very differently. They remained convinced of their memories even after they were confronted with their own handwritten journals. Burton quotes one student as saying, "That's my handwriting, but that's not what happened." Amazing!

David Allen, March 31

Leslie,

I think we are in substantial agreement. Of course memory can be extremely faulty, can be altered by subsequent events, etc.

I just get a little nervous when this is brought up because people with the agenda of minimizing the extent of child abuse in this country are likely to go all Elizabeth Loftus on us.

Someone actually did a study that showed the obvious conclusion that the more familiar something is to you, the less likely you are to misremember it.

People bring up that DNA evidence has shown that women who have been raped frequently misidentify their assailants in a police line up, especially if there are people in the lineup that happen to look alike. I feel reasonably certain however, that if the assailant was the victim’s own father, this would be far less likely to happen.

Also, 75% of the sample you quoted got it right.

Leslie Phelps, March 31

David,

We are clearly in agreement. And, as far as the application of memory research to people with histories of abuse, I couldn't agree more. You also rightly highlight that the majority of the subjects in the study I referenced got it right.

Tyler Carpenter, March 31

The late Leopold Bellak would have been inclined to agree, David.

When you patients might die or hurt or kill someone else, this makes a difference in how you think about things. A real existential bottom line. Bellak (MD/PhD) told our small seminar that he felt it was medical training's life and death training component that made them "dither/obsess" (his rather colorful if unfortunately candid phrase) less than psychologists who did not have to make life and death decisions. I credit my prison experience with really deepening my clinical skills and aesthetic appreciation in numerous ways. Good clinicians, staff, and cons appreciate an honest, straight, and just bottom line.

Tullio Carere, March 31

This is my formula connecting bracketing and dialogue:

Bracketing one's biases is of little use, and even misleading, if it is done just inside one's skull, but extremely powerful if it is done in dialogue. Dialogue is frustrating and almost powerless for those who enter it wearing all their beliefs, but is the key that opens most relational doors for those who enter it naked.

Tyler Carpenter, March 31

I would agree with that absolutely, Tullio. A lot of ways to get there.

Tullio Carere, April 1

David,

the dialogic paradigm (short for dialogic-dialectical paradigm) that is my existential and professional horizon is not just "being open to information that calls our pet psychotherapy theories (or our hypotheses about a particular patient) into question", let alone "using a Zen-like state of mind as the predominant therapeutic technique". It is a frame of mind -- better said, maybe, a frame of no-mind -- that allows for all kinds of personal and professional interactions without getting entangled in or conditioned by any of them. Let me try to explain. I started my psychiatric residency a little before you, in 1970, worked six years in the public mental health services, then resigned for a full time private psychotherapy practice that lasts to the present day and, in my intention, to all my future days (as a young man I decided that I would never be a pensioner). My deal with life was and is that it keeps me alive only if I do something useful for the people to whom I relate, besides myself. As all my clients pay out of their own pockets, because insurance coverage is practically non existent for psychotherapy in my country, you may understand that if I had sold navel gazing I could not have survived for the last thirty plus years. So, what do I sell?

Firstly, I don't forget that I am a MD and a psychiatrist. I agree with you that therapy "should be a treatment for something, not just a vehicle for personal growth". This is one of the many dialectic polarities that orient my practice -- this is why I call it dialogic-dialectical. There cannot be a personal growth without a treatment, because existence itself, in its "normal" version, is a sort of illness, as the great psychiatrist Buddha taught so many centuries ago. The basic illness takes many forms -- I would say: as many as there are individual human beings -- but there are typical patterns which a therapist should be familiar with. The treatment itself shows typical patterns across different theoretical orientations, which we call common factors. Empirical research (sorry Paul if I go on using this term) cannot describe the typical patterns of our field, because to describe a phenomenon you must define what essentially belongs to it, which empirical science cannot. Modern science was born four hundred years ago in Florence with Galileo, who stated "I don't try the essences". Empirical science has had the extraordinary development it has had because it has renounced the essence, the study of what is essential in things, to concentrate on what can be measured and objectified. Therefore my practice basically builds upon observational research of the phenomenological sort, with only secondary and marginal contribution of empirical research.

I am in total agreement with David Reiss who wrote: "Without integrating psychopharm with psychotherapeutic intervention, there is at best a broad 'shotgun' approach, and, in my experience, not infrequently, the result is significant episodes of iatrogenic counter-therapeutic responses". Psychopharm guided by empirical research based protocols, as it is mostly done, is in my view too responsible of a great lot of iatrogenic damage. Empirical research can only say that generally, statistically, one can expect a given effect from the administration of a drug. But the meaning of the administration of a drug -- as of any psychotherapeutic procedure -- in a specific existential context is what really counts for real therapy. And the authentic meaning -- as opposed to the meaning a symptom or a behavior or an experience takes within a given theoretical frame -- can only be investigated in a frame of mind that brackets all theories. It is basically the old Greek frame of mind, in which truth is not a theoretical construction, but aletheia, unveiling of the truth of the logos. Correspondingly, therapy is not the treatment of this or that disorder, as the DSM culture wants us to believe. Therapy in its essence is care of the self, i.e. giving the self the care it needs to its realization. Aristotle had a word, eudaimonia, which is translated both as happiness and as good life: the life that is oriented to its accomplishment according to its essence, which is that of a zoon logon echon (an animal that has the logos as its essence) and a zoon politikon (a relational animal). It is impossible to understand the meaning of any DSM disorder for the life of a man, unless it is investigated against the background of his or her life as a whole in a dialogic relationship -- or better, a network of dialogic relationships -- that allows for the truth of the logos (of the existential process) to manifest itself.

To the extent that I am grounded in the logos -- to the extent of my F in O, in Bion's terms -- I can (and must) do whatever the logos -- i.e. the logic of the process -- suggests me to do. It is not a matter of eclecticism, but of logic. If the patient is not responsive enough to a conventional psychotherapeutic approach, say psychodynamic or CB, it is obvious that I must do something else. Many times psychotherapy is possible only thanks to a psychopharm support, which I frequently give in the same perspective as David Reiss' (never give a psychotropic drug outside a psychotherapeutic relationship). Besides, most of the times it is clear, not just with borderline patients, that therapy cannot do much, unless some work on the patient's relational network is done. Therefore I do a lot of monitoring of external relationships, besides much couple and family therapy -- like you, I understand.

The Greek word logos is usually translated with the Latin ratio. But the logos is much more than reason and speech, as the therapy is much more than talking cure. As Eraclitus pointed out, the logos is the matrix, the source of all conflictual drives, of all life's dialectical polarities. Every therapist knows that reasoning is ineffective, if it is not connected to emotional experience. Experiential therapists have explored many ways to elicit deep emotions. In my experience, the patient's suffering often has very deep roots -- it starts very early in life, it is located very deep in the brain. It is often impossible to get in touch with such early experiences if one remains on the verbal level. One has to engage the body. I regularly employ deep breathing and bodily holding to this aim. I have found that the experience of intimacy created by bodily touch is a most powerful therapeutic factor. Many therapists shun bodily touch because they are afraid of the erotic involvement that it can unchain. But the erotic transference-countertransference matrix is in turn a most powerful therapeutic factor, provided that eros is enlightened by logos: only unenlightened eros is dangerous, because it can drive the relationship in counter-therapeutic directions. As I can foster bodily intimacy only with female patients, with male patients I often need a female co-therapist, who can be the patient's partner, in ideal but not exceptional cases, or recently my wife, who is an artist and a counselor.

Nihil humanum mihi alienum est, I could say with Terentius: could be the motto of the dialogic-dialectical paradigm. Now your final question: how can all this be done bracketing memory and desire? Don't I need memory in order to formulate and follow therapeutic plans, and a strong therapeutic desire to fuel them? Yes, I need memory, desire, and the knowledge accumulated in the study of medicine, philosophy, and psychotherapy. Yet if I wear all this in the dialogue with my patient, the logos cannot descend and dwell between us, because all the room is encumbered with my memory, desire, and knowledge. Therefore I have to bracket it all, and leave it to the logos to recover, in due time, the memory, the desire, and the knowledge it needs.

Tullio Carere, April 4

Hi Tyler, you wrote:

I suspect that we are all closer than we might think. At it's heart and stripped down to the basics, the process you describe is well known for millennia: following the breath and watching how the process of thought moves to create the illusion that is reality.

Well, almost. Your sentence sounds to me very eastern-style: The world is maya, an illusion created by the cosmic mind, which is the true reality. The western mind has it mostly the opposite way: The material world is real, the mind is just a product of the brain as the bile is of the liver. Thank you for giving me an occasion to try to make it clearer why I call my approach dialectical, besides dialogical. Basically, Hegel's point was that nothing is what it is, if not by contrast with what it is not. The illusion is neither the subject nor the object, but the idea of considering one as independent of the other. This does not mean that what is real is the synthesis: the synthesis is just one fleeting moment of the process, because every synthesis soon becomes the thesis for a new antithesis, and so on. Heraclitus saw perfectly well this state of affairs. All is conflict, he said, but their is a hidden harmony in this cosmic war. Therefore he invited to listen to the logos, i.e. to trust the whole process, in spite of its apparent contradictoriness. In my view, this is what Jasper's philosophical faith and Bion's faith in O are all about. When the basic faith in the logos, i.e. the process, is lacking, one inevitably tries to interpretively, cognitively or behaviorally master or control the process, instead of freeing it, furthering it, tuning to it.

Although I sent my previous contribution, a response to David Allen, on April 1, I want to assure that it wasn't an April fool: I really employ bodily holding in my practice: see my paper Bodily holding in the Dialogic-dialectical approach, Journal of Psychotherapy Integration. Vol 17(1) Mar 2007, 93-110. As in other occasions, I was told back-channel that everybody in the US is frightened by physical touch with patients, because of the risk of it being experienced or interpreted as sexual harassment. Maybe times are changing, though. In a recent discussion on the JAPA netcast I presented a case of bodily holding that had a clear erotic quality to it. It was met with a resounding silence, as usual, but the editor of a psychoanalytic journal wrote to me back-channel that they were willing to consider for publication an article including that case.

Ps. Tyler, I always read with great interest your contributions, but very often I am not sure what you are talking about, because your English is a little too difficult for me.

Luca Panseri, April 4

Tullio wrote in his last message :

<<As in other occasions, I was told back-channel that everybody in the US is frightened by physical touch with patients, because of the risk of it being experienced or interpreted as sexual harassment. Maybe times are changing, though. In a recent discussion on the JAPA netcast I presented a case of bodily holding that had a clear erotic quality to it. It was met with a resounding silence, as usual, but the editor of a psychoanalytic journal wrote to me back-channel that they were willing to consider for publication an article including that case.

Yes, may be times are slowly changing. I found other interesting examples of it listening to a series of conversations on psychotherapy - Somatic Perspectives on Psychotherapy - edited by Serge Prengel http://www.somaticperspectives.com/

For those who are interested in the use of touch in therapy I would suggest Serge Prengel's conversation with Kathy Kain ( http://www.somaticperspectives.com/ for the printable version).

Thanks Serge and Tullio for making us aware about the fundamental role of physical touch in psychotherapy.

Tyler Carpenter, April 4

Hi Tullio,

I appreciate your thoughtful reply as always. Although my grammar can be challenging at times (by temperament, submersion in all of American culture, working in the public sector, and a personal taste for jazz and poetry, I long ago gave up an insistence on some sort of absolutest grammatical correctness), I think what we have here is a bi-personal and conceptual bridge to cross.

You are quite correct about the Eastern cast to my remarks. It was only after reading Eastern philosophy and meditating at the "suggestion" of the neo-Freudians (Erich Fromm), Jungians, and American hip like Alan Watts, that I found my way back to Western mysticism in the form of Thomas Merton, "The Cloud of Unknowing", and to borrow Eliot's line, "knew it for the first time." Zen culture and art (both samurai and haiku) have a deep resonance with with my WASP roots, though like the Emperors of the Tang Dynasty I deeply appreciate the necessity of supporting all three philosophical traditions (Buddhist, Taoist, Confucianist) and their Western equivalents as necessary to not only practical understanding, but real aesthetic appreciation.

I have yet to know Hegel more than wiki-deep, but know Heraclitus quite well (used some of his work and a zen aphorism as the title of my last SEPI presentation) and don't see the conceptual differences as mutually exclusive as you seem to. Perhaps you are not taking Hegel to heart and instead regarding the fleeting synthesis as more permanent than it really is. IME and O the practical effect of following the path of wou-wei/the breath/cleaning ones bowl/polishing the mirror is no different than that you so carefully describe below. The mind may be what the brain does in context, but in the end it is illusory, categorizing, and each momentary synthesis is both a transitional object for the intellectual and an indivisible part of the endless stream of consciousness for those who like to sail or surf their consciousness (as though we ever ultimately do anything else). I suppose that I could transpose what you have said in a manner that would draw more connections between your carefully constructed and referenced concepts and language and my more metaphorical and beat style of speech and thought, but the signifiers I'm using don't seem to be that big a stretch for someone of your obvious learning and erudition. Though I do find myself wishing I had kept up my Latin so I had a better chance of one day reading great Italian philosophers and writers like Umberto Eco in their original Italian.

I too have used touch, and limbic music, in my work since before I became officially licensed to be therapeutic (like the classically trained modern artist or jazz musician, the training is tremendously valuable, but requires a lot of unlearning to be truly helpful). One can bootstrap a lot with little through informed and insightful boundary crossings. It was quite clear to me as I watched my self and teachers in action that eroticism and a lack thereof, were always present, but to lose touch with its life giving force or to confuse it with sex wasn't good for anyone. I don't violate my patients and generally leave it to others who are drawn to such distinctions to explain it or demarcate its boundaries and use for themselves and others.

As always I appreciate your thoughtful responses and the challenge to clean up my linguistic and philosophical act.
PS - Your language and conceptual distinctions are always crystal clear and elegant, Tullio. I'm afraid, being a bit of an iconoclast myself, I sometimes break the conceptual Byzantine art, but then there is a well loved Mediterranean custom of smashing crockery in times of joy and celebration, No?

Tyler Carpenter, April 5

This article below seems like an interesting integrative SEPI question ? What is "drift" and how would one know ? If a CBTer is "drifting" why is that the case and if a patient gets "worse" why is that happening? Given the recent dipping of the collective toes in epistemological waters (Hericlitean or Materialist?) is this a question of looking for our keys where the light is (Sufi) or would a more Socratic approach give us a "real" answer ?

*Behaviour Research and Therapy* (Volume 47, Issue 2) includes an
article: "Evidence-based treatment and therapist drift."

The author is Glenn Waller.

Here's the abstract:

"Cognitive-behavioural therapy (CBT) has a wide-
ranging empirical base, supporting its place as the evidence-based
treatment of choice for the majority of psychological disorders.
However, many clinicians feel that it is not appropriate for their
patients, and that it is not effective in real life-settings (despite
evidence to the contrary). This paper addresses the contribution that
we as clinicians make to CBT going wrong. It considers the evidence
that we are poor at implementing the full range of tasks that are
necessary for CBT to be effective - particularly behavioural change.
Therapist drift is a common phenomenon, and usually involves a shift
from 'doing therapies' to 'talking therapies'. It is argued that the
reason for this drift away from key tasks centres on our cognitive
distortions, emotional reactions, and use of safety behaviours. A
series of cases is outlined in order to identify common errors in
clinical practice that impede CBT (and that can make the patient worse,
rather than better). The principles behind each case are considered,
along with potential solutions that can get us re-focused on the key
tasks of CBT."

David Allen, April 5

"Cognitive-behavioural therapy (CBT) has a wide-
ranging empirical base, supporting its place as the evidence-based
treatment of choice for the majority of psychological disorders."

What a ridiculous claim! Many CBT studies have a stupendous number of obvious flaws which many of SEPI members and other therapists have identified, which I don't have time to go into here. Snake oil!

When it comes to CBT therapy for personality disorders, DBT and Schema Therapy borrow liberally from other schools. I also have a video of Donald Meichenbaum, who I think may have even coined the phrase "CBT," in which he compares a patient's reactions to her husband to her reactions to her father when she was a child! Sounds psychodynamic to me, or at least interpersonal.

I guess one could say that CBT is the "treatment of choice for most psychological disorders" if it casts such a wide net!

Tullio Carere, April 6

This most rich discussion seems to have come to an end.

Thank you everybody. See you next year in Florence.

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