Psychotherapy Integration Papers

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Psychotherapy Integration

SEPI Forum: January - March, 2006

Section I: January

Read the listserv discussion during  February   March, Part I  March, Part II

Editor's Note
In preparation for the 2nd Sepi- Italy Conference, held in Florence from 24 to 26 March 2006, Tullio Carere asked the speakers of the Conference and the members of the Sepi listserv to participate in an on-line debate. In his e-mail dated 22 January 2006, Carere proposed a series of questions which have been the starting point for a rich and passionate discussion among 16 participants (listed in the order in which they intervened) : Tullio Carere, Paul Wachtel, John Norcross, George Stricker, Allan Zuckoff, Hilde Rapp, Tyler Carpenter, Ken Benau, David Allen, Andre Marquis, Paolo Migone, Stephan Tobin, Barry Wolfe, Zoltan Gross, Luca Panseri, Mike Basseches.

Dear colleagues and friends,
I have asked all the presenters at the Florence SEPI Conference (March 24-26, 2006,
http://www.vertici.com/sepi/ ) to shortly comment on a few questions that roughly describe our topic.  Here are the questions:

Dealing with integration means to deal with what divides the psychotherapists
. Why are psychotherapists so much divided, in comparison to cardiologists or endocrinologists? Maybe because psychotherapy is not a science? Or because, as some maintain, it is not yet a science, but it will become one when psychotherapists will decide to submit to the rules of all good science, from physics upwards, getting out of the medieval darkness like all other branches of medicine? Or rather because psychotherapy is not at all a branch of medicine? Shall we admit that there exist two quite different practices, one of medical type, based on psychopathological diagnoses and empirically supported therapeutic procedures, the other of humanistic type, in which the meaning of the disorders and of the ways to cure them does not come out of diagnostic and therapeutic manuals, but of therapeutic dialogue and context? In that case, shall we surrender to the irreducible diversity of the two approaches, acknowledging that treating a patient is incomparable with caring for a subject, or shall we understand them as the two terms of a polarity, inside which every therapist can conveniently locate himself or herself according to temperament and preferences?

I hope some of you will want to join us in the discussion on this listserv.

Paul Wachtel, 22 January 2006

In my own view, the matter is not as dichotomous as it can seem to be in some interpretations of the questions posed.  I do not think that our divisions are easily explained in terms of simply whether we are a science or not.  I say this in part because I think that the term "science" itself is – or should be – a manifold term, not a singular, prescriptive term.  I say it as well because some of the divisions, some of our difficulties in achieving consensus are due to the subject matter of our science being extraordinarily ambiguous and difficult to address in very general ways rather than it being intrinsically inaccessible.  (They also derive, as I shall comment on shortly, from the very strong connection of our particular subject matter with values and identity).

    To begin with science: To my mind the essence of the scientific method is to take seriously the very things that we, as psychotherapists, particularly should understand.  That it is very easy to deceive ourselves, that our memories are suspect, that it is hard to hold onto very much without recording it systematically, that our very perceptions are subject both to motivated and to unmotivated skews and distortions.  The scientific method – no, I am already slipping into a singular when it should be a plural; scientific methods are that quite considerable variety of ways in which we try to minimize or reduce those effects (we can never eliminate them, only reduce them).  
    The problem is that we almost have a variant of the Heisenberg principle operating – not so much in terms of our role as observers changing what we observe (though that, of course, is also true), but in terms of the tradeoff that is entailed.  In quantum physics, the more we know about the position of a particle, the less we know about its velocity and vice versa.  The very knowing of one reduces our knowing of the other.  In psychology, the tradeoff I have in mind is a little different.  It is that the more precisely we know something, the more we can use "traditional" scientific methods, often the less useful or comprehensive or directly applicable is that knowledge.
    This is not quite as airtight as it is in quantum physics, which is why I said "almost" a variant of the Heisenberg principle.  Sometimes, very precise experimental studies are about very crucially important things, and the refusal to acknowledge that can be a rationalization for laziness or for continuing to do what one is used to rather than responsibly paying attention to the evidence.  But all in all, the tradeoffs are significant.  The kinds of phenomena that psychoanalytic therapists and theorists are interested in, for example, the subtle issues of affect, conflict, motive, the concern with the edge of experience, with what is not yet expressible, etc – these are hard to address with traditional experimental studies (though even here it is important to acknowledge that some very important work has been done in this regard).
    I do believe that sometimes we parrot the models of physics, say, or of medicine, to the detriment of our discipline.  We need to find the kinds of disciplined observations and systematic recording of data that are appropriate to the questions we are asking.  At our present level of knowledge, for example, one of the technologies that is most relevant is the by now humble one of video and audiotape recorders. This permits several extremely important things to be added to what Freud, say, was able to see, remember, and check on.  First, and very important, it allows others to see the same material (though there are of course differences between seeing a tape and actually being there in the affective field with the patient – no solution is perfect).  Second, it permits the therapist him or herself to check on what has been remembered.  It is striking how different a sequence can be when one watches it on tape from what one has remembered (and the subtle differences are just as important as the dramatic and obvious ones).  Third, sometimes we only see something that has, in essence, been lying there waiting for us to notice, after looking at it many times.  In one of my very first published papers, concerned with what is communicated by body language, I described a pattern I did not see until I looked at the tape an enormous number of times.  But once I finally noticed it, it "jumped out" at me and became rather obvious.
    This is just one example of a "scientific" advance over just reporting what one remembers from one's sessions, often at the end of the day or even days or years later looking back on the case.  I mention the tape recorder precisely because (a) these days it is a rather humble instrument, available to most children let alone adults, and yet it is something that Freud simply could not conceive would be available to psychoanalytic research; (b) it is a method that basically retains the usual focus of the intensive psychotherapist.  That is, it simply records the effort to be empathically attuned to the patient's affect state, etc, rather than diverting that effort.  It still requires a good deal of inference and interpretation to maintain certain views, but the argument has a somewhat more solid foundation. (Some people argue that to record a session totally changes the configuration of what is transpiring.  I believe that to be a self-serving rationalization for not exposing either one's clinical skills or one's ideas to this kind of scrutiny.)
    More complicated or technologically advanced ways of improving on what we can know just from sessions are, of course, also available, often in the form of some kind of physiological or neurological recording, but consisting of many other methods as well.  There, we quickly find ourselves on the slippery slope of tradeoffs I referred to above.  But although we may not be able to completely resolve that dilemma, I believe we do a better job of zeroing in on what we need to know by shifting back and forth to some degree from one end of the tradeoff slope to the other. That is, sometimes shifting away from our "intuition" toward considering what a particular experimental finding suggests, even if its ecological validity can be in question; sometimes, shifting away from what the "findings" are that seem to emerge from certain studies because one is paying attention to what one's affects, interpersonal and empathic connections, etc are telling us.  After all, Luborsky has shown that usually the researcher's own orientation comes out ahead even in carefully conducted studies of therapy that seem "objective."  Giving credence to what the physicist and philosopher Polanyi called the "tacit" dimension or tacit knowledge is an important corrective to ideologically driven scientism.
    So again, in my view, the biggest problem is falling into an either-or dichotomy.  And, in my view, there is a danger that the seemingly ecumenical "both-and" stance can itself be an unwitting falling into dichotomy because it implies that the two sides being equally considered and valued are two totally different sides.
    So, to return to the main set of questions, I do not think " there exist two quite different practices, one of medical type, based on psychopathological diagnoses and empirically supported therapeutic procedures, the other of humanistic type."  And I say this even though I am a  very strong critic of the ideology that "empirical validation" means manuals.  In my work with patients, and in my theorizing, I sometimes am going along paying attention to my subjective experience of being with someone when a "finding" occurs to me that alters what I am doing and how I am seeing and experiencing what is going on between us.  And in my reading of the research literature, I am attentive to the methodology, and (apropos what I just said) am seriously respectful of the content of the findings, but I am also simultaneously thinking about it in terms of what my experience in life has been of what it is to be a human being, to be in a relationship with another person, etc.
    I guess maybe that is why I am a SEPI person.  I am not a dichotomist by and large (you could certainly find some places where I am, especially in the realm of politics).  I tend to look at both sides not just in terms of theories (psychodynamic, cognitive-behavioral, family systems, experiential, etc.) but also in terms of methodologies and perspectives (empathic immersion, controlled experiments, etc.)

Tullio Carere, 23 January 2006

Dear Paul,
thank you for your precious response. As you begin by saying "In my own view, the matter is not as dichotomous as it can seem to be in some interpretations of the questions posed", I want to clarify that in my view the scientific-humanistic dichotomy, before being a matter which one can approve or disapprove of, is a matter of fact. I often cite B. Carey's incipit of a noted NYT 2004 article that depicts the way the world looks at us:

Good therapists usually work to resolve conflicts, not inflame them. But there is a civil war going on in psychology, and not everyone is in the mood for healing. On one side are experts who argue that what therapists do in their consulting rooms should be backed by scientific studies proving its worth. On the other are those who say that the push for this evidence threatens the very things that make psychotherapy work in the first place.

If we acknowledge this fact in the first place, what follows next is what we decide to do with it. We can consider it as just the result of a simplistic attitude in our field regarding the scientific method (or methods, as you say and I agree), and the difficulty to understand the extraordinary ambiguity of our subject matter. Or, beyond that, we can see in the split of our field the reflex of a contradiction that has not yet been dialectically articulated, and is consequently stuck in a sterile opposition. As you fittingly observe,

<<The problem is that we almost have a variant of the Heisenberg principle operating – not so much in terms of our role as observers changing what we observe (though that, of course, is also true), but in terms of the tradeoff that is entailed.  In quantum physics, the more we know about the position of a particle, the less we know about its velocity and vice versa.  The very knowing of one reduces our knowing of the other.  In psychology, the tradeoff I have in mind is a little different.  It is that the more precisely we know something, the more we can use "traditional" scientific methods, often the less useful or comprehensive or directly applicable is that knowledge>>

I am struck by you reference to the indetermination principle, because I myself am working along the same line. My own formulation of that principle, applied to our field, is: The more objectively we want to know the phenomena happening in a therapeutic relationship, the more the subjective side of the same phenomena - emotions, meanings, values - eludes us, and vice versa. The unawareness of this principle is in my view the basic cause of our "great divide". At the two sides of the divide stand respectively those who privilege objectivity (therefore aiming at a psychotherapy akin to medicine, in which disorders are identified through diagnostic manuals and treated by means of empirically supported procedures), and those who privilege subjectivity (therefore being little interested in diagnoses and procedures, but much in the emotions elicited and the meanings made or uncovered in the process).
 
To heal the split means to me to recover a dialectic of the subject and the object, transforming the dichotomy in a polarity in which neither term is privileged a priori. The implications for research are far reaching. On one side traditional psychoanalytic research, which considers only subjective data, on the other empirical research (especially the one of randomized clinical trials), which is only interested in reproducible and measurable data, have produced a situation of impasse and reciprocal incompatibility. I believe that the impasse can be overcome starting from two basic points.

The first is the acknowledgment by the therapists of the necessity of documenting their work not just with clinical notes, but also with audio- or video recording (as you prefer) or post-session questionnaires (as I prefer). In this way the object of study is real therapy, not a laboratory artifact, and the data obtained are of a documental, not experimental type. The second point regards the way of processing the data. The data of a process, be it of historical, juridical, psychological or narrative nature, do not lend themselves very much to mathematic-statistical processing: what they essentially need is interpretation. Basically, to overcome the subject/object dichotomy a research in psychotherapy should integrate the therapist's interpretation of whatever transpires in the session (subjective data) with the interpretation of process documents (objective data). This is what I do in my minuscule research group, and what in my view every single therapist could and maybe should do, in the spirit of the Freudian Junktim: the inseparable connection between theory, practice, and research.
 
Thank you again, Paul, for your contribution to our pre-conference discussion (I have forwarded your text to the Italian conference discussion list), and especially for your reference to the indetermination principle (almost).

John Norcross, 24 January 2006

To understand the psychotherapies, one must appreciate both the robust commonalties that unite them and the enduring differences that separate them. To appreciate only the undifferentiated, lowest-common denominator mass is to miss the clear distinctions among component parts. To appreciate only the precise distinctions of the components is to miss the larger gestalt. We should strive to  integrate the differentiated parts into the whole at a higher level.  Here, we can understand the unity and the complexity of psychotherapy.  It is to this level, I believe, that psychotherapy should aspire.

    In clinical work, we can combine the power of the common factors and the specificity of the differences. In fact, many of the differences among the psychotherapies are complimentary when working with patients.  Disparate treatment content and goals of the psychotherapies, for example, can be prescriptively matched to the clinical needs and treatment preferences of individual patients. Different psychotherapeutic methods have been shown to be differentially effective for patients in different stages of change, for another example.  The insight-oriented and motivation-enhancement methods are indicated for patients in precontemplation and contemplation stages, while more cognitive and behavioral methods are indicated for patients in the action stage.  And highly directive and paradoxical methods have been shown to be more effective for high-resistance patients, for a third example. Different strokes for different folks.

    Finally, I am deeply concerned about the tendency to bifurcate the field of psychotherapy into bipolar camps:  insight vs action therapies, objective vs. subjective therapies, or, as implied in the stimulus question, medical model vs. contextual model.  It serves neither our discipline nor our clients. The alternative is not to deny real differences; the alternative is to avoid dichotomous experiences and to appreciate both the unity and complexity of psychotherapy, using the real differences to enhance outcome by tailoring psychotherapy to the individual client and the singular situation.

Tullio Carere, 25  January 2006

Thank you John for sharing with us your deep concern "about the tendency to bifurcate the field of psychotherapy into bipolar camps:  insight vs action therapies, objective vs. subjective therapies, or, as implied in the stimulus question, medical model vs. contextual model", and your belief that "it serves neither our discipline nor our clients", coupled with the belief that "the alternative is to avoid dichotomous experiences and to appreciate both the unity and complexity of psychotherapy, using the real differences to enhance outcome by tailoring psychotherapy to the individual client and the singular situation."

I myself am a believer in the unity and complexity of psychotherapy (although I do not believe in the uselessness of the bipolar perspective). Of course you are aware that we live in a world of infidels who don't believe in the unity of psychotherapy. For instance, in psychoanalysis the believers in a common ground are called the "common grounders" and are said to be one of the five or six major psychoanalytic tribes living in a reserve, watched over with suspicion or open hostility by all the other tribes. According to the First Law of Discussions among Psychotherapists, whenever a psychotherapist says that psychotherapy has the X property (e.g., it has robust commonalities), there always is another therapist who says that his or her thing does not have the X property (e.g., there are at most family resemblances). Our field produces dichotomies as other fields produce daisies. But it seems to me that there are many more people allergic to dichotomies than to daisies.
 
In my view nothing is wrong with dichotomies, mostly. To the contrary, dichotomies are there to correct therapists' and theorists' one-sidedness. Behavior therapy was born to expose psychoanalysis' one-sidedness. Insight vs. action therapies is a useful dichotomy, because it exposes the one-sidedness of both. It is good, but not good enough. The really good thing is when someone transforms the dichotomy into a polarity. That is, when someone understands that insight and action are not two definitively and insuperably different things, but the two terms of a "cyclical dynamics", as Paul called it in his pioneering work. This is how dialectics works: the apparent separateness and one-sidedness of the two terms of a contradiction is transcended (aufgehoben) when the relation connecting the two is seen and implemented. In the same vein, the current dichotomy between practice and research can be transformed into a polarity if the two are no longer seen as two separate things made by different operators with different competences, but as the two sides of an integrated enterprise, as I have tried to sketch in a previous posting.
 
I stop here, because allergy to dichotomies is nothing, compared to the almost anaphylactic crises unchained by dialectics in some friends and colleagues, and I don't want to stress their immune system.

George Stricker, 25 January 2006

I'm not sure that John and Tullio really disagree, but whether they do or not, let me indicate where I stand on this. I agree with John that the creation of bipolar camps is not constructive, and often the polarities are given life and exclude the other. However, I agree with Tullio as to the value of a dialectic process, and that begins with opposing views that then can be reconciled for a higher order solution (which, in turn, gives way to further opposition and resultant syntheses, in a continuing process). As for science and practice, my views are in my writing on the Local Clinical Scientist, a formulation that has the clinician acting as a scientist in a laboratory with the patient, maintaining attitudes of skepticism and inquiry, and learning from each encounter. This requires the systematic record keeping that Tullio discussed earlier in order to be effective.

Allan Zuckoff, 25 January 2006

Dear Tullio,
I’ve enjoyed reading this exchange, and have been glad to see a reemergence of substantive discussion on this listserv. I join the discussion as a psychologist trained in empirical-phenomenological research methods who has spent much of the past decade involved in controlled trials of psychotherapy interventions, and thus as someone who has sympathies for both sides of the dichotomy (or poles of the dialectic, if you prefer).
 
In one of your posts to Paul, you wrote:
<<I believe that the impasse can be overcome starting from two basic points. The first is the acknowledgment by the therapists of the necessity of documenting their work not just with clinical notes, but also with audio- or video recording (as you prefer) or post-session questionnaires (as I prefer). In this way the object of study is real therapy, not a laboratory artifact, and the data obtained are of a documental, not experimental type.>>

I agree that the object of psychotherapy research should be, as you put it, “real therapy.” I gather, though (based on past listserv posts), that you do not consider time-limited, protocol-guided therapy provided in the context of a research study to fit that description. If I’m correct in this understanding (and I apologize in advance if I have misconstrued you), then this is perplexingly dismissive of the powerful effects such therapies have been repeatedly demonstrated to have (as well as of the “reality” of the therapeutic encounters I have experienced in doing such therapies). It would also deprive us of excellent sources of the data that I think interests both of us the most: live, meaningful interactions between therapist and client.
 
Relatedly, I am also perplexed by your suggestion of an equivalence between recordings of therapy sessions, and post-session questionnaires. From an empirical perspective, research on training of therapists in motivational interviewing (the area with which I am most familiar) has shown that the gap between what therapists think they are doing, and what recordings show them to have been doing, is rather substantial (especially with regard to expressed empathy). From a psychoanalytic perspective, this should hardly be surprising: no matter how well-analyzed, therapists have their defenses, and their own assessment of what has happened and what they have done in a session should reliably be expected to be distorted in various ways. For access to the rich intersubjectivity of therapeutic process, it seems to me that there can be no substitute for recording of sessions.
 
I’ve chosen to address two of your specific points, rather than the overarching theoretical and conceptual issues, because I think it’s in such points that the challenges of psychotherapy integration become most clear. If agreement is impossible on points such as this, then it’s hard for me to see how the rifts you have highlighted can be healed. If synthesis can be achieved on such questions, however, perhaps there is more hope.
 

Hilde Rapp, 26 January 2006

Tullio observes/ asks:
<<Dealing with integration means to deal with what divides the psychotherapists
. Why are psychotherapists so much divided, in comparison to cardiologists or endocrinologists?>>

All knowledge, as Bion so astutely observed, requires linking that which is similar and separating that which is dissimilar or different – all thought and all language depends on making distinctions. Psychotherapy has in common with the natural sciences that part of the activities of practitioners of psychological therapies  consist in observing the client’s behaviour, noticing regularities or patterns, and finding ways of systematizing these observations through description, where possible measurement, and through searching for  regularities and consistencies  in the relations between observations – something akin to formulating rules, laws and theories.  Psychiatric classification depends on such systematizing work, including certain behaviours, signs or symptoms in the description of  clients disordered thoughts, feelings  and behaviours   and excluding others in order to arrive at a differential diagnosis.
 
Psychotherapy is dissimilar from the natural sciences and similar to the Geisteswissenschaften  ( sciences of the mind – what anglosaxons call Human sciences and  the arts), in that it also enquires into subjective  and cultural acts of meaning making by exploring with clients through questioning and spontaneous self report , their own efforts after assigning meaning and significance to the content of their consciousness. This activity draws on culturally mediated symbols and metaphors as well as  subtle distinctions between affect states such as regret, remorse,  repentance, shame or guilt  and culturally mediated story grammars or forms of narrative. The negotiation of such intersubjective  meaning and perhaps even transpersonal experience can be tapped by methods of measurement as for instance in discourse analysis, both of key words and of non verbal signs, such as hesitation patterns, inflection and so forth. More usually, therapists draw on their own capacity for artistic appreciation and, significantly, for  empathic understanding of the client’s communications, whether verbal or nonverbal,  whether in the form of  reports of dreams and fantasies or of  reports of social or natural events, in ways akin to those used by writers,  poets, dramatists, film makers and visual artists.

Tullio poses the questions:
<< Maybe because psychotherapy is not a science? Or because, as some maintain, it is not yet a science, but it will become one when psychotherapists will decide to submit to the rules of all good science, from physics upwards, getting out of the medieval darkness like all other branches of medicine? Or rather because psychotherapy is not at all a branch of medicine?>>

I largely agree with the points already made eloquently by Paul and by John. Although these questions are common, and although I very much like questions,  I do not think that  we should be seduced into providing dichotomous answers!. As you will see from my contribution to the conference  which also  reflects the structure of my forthcoming book, my understanding of integration  depends on respecting that human beings  have only partial access to what may be known about  ourselves and the  world. We do not have a coherent theory of everything- and, Wilber not withstanding,  in some ways I rather hope we never will. Furthermore, we  are prisoners of language when it  comes to what can be said about what we know, and therefore we express what we know according to different traditions of enquiry. Paradigms, epistemologies  and traditions arise in ways that are the best  fit for the purpose of examining, describing, measuring or classifying  the phenomena we wish to understand at a given time in history. Each age brings revisions, redecisions and innovations, some clearly advances, others cul de sacs born of fad or fashion – whether often only time can tell which is which.
 
In my view the task of integration is to establish correspondences or links between  the way we describe ( what we hope is)  the same phenomenon in one paradigm and how we describe it in another.  .
 
I use four simple distinctions to map the field- each of which connects into a particular tradition of enquiry:
 I. Exploring subjective experience
 II. Exploring cultural patterns of meaning making
III.
Examining  and measuring bio-social determinants
IV. Investigating the  effects of the social-political- environmental- economic  regulation of society

For instance: We may become curious about  correspondences between physiological events such as hormone function, brain transmitter activity  ( III) and thoughts, feelings, dreams or motivational events etc ( I ). We may want to track such patterns, insofar as we understand them through the life span- how do they change with age and experience (III) ? Whatever we do will be subject to interpretation (I), and our interpretations of any findings are culturally situated (II).  Furthermore, they tend to have political implications, in that  moneys will be allocated  ( or not) to research further, and  recommendations will be made  via  guidelines  to regulate access to treatments or resources (IV). Integrative therapists need to negotiate the different ways in which communities of enquiry, meaning, interest or practice  use epistemologies and language to share their knowledge and also to mark it off from the discourses of other disciplines with a related but different focus of enquiry. This requires adopting a meta-perspective and , alas, a good deal reading and thinking outside the box without loosing one’s humility in the face of the complexity of what we are trying to understand, and crucially to apply to responsible practice with often vulnerable clients.
 
Tullio asks:  
<<Shall we admit that there exist two quite different practices, one of medical type, based on psychopathological diagnoses and empirically supported therapeutic procedures, the other of humanistic type, in which the meaning of the disorders and of the ways to cure them does not come out of diagnostic and therapeutic manuals, but of therapeutic dialogue and context?>>

 Yes there are different traditions which are linked to different practices which serve different social functions. Traditionally  diagnostically driven psychiatry  is designed to observe,  diagnose,  and then treat  socially divergent behaviour. Its aim is to restore the client or patient to a socially adapted/ adaptive state in which his or her behaviour fits within normal parameters. It is a corrective practice and can be and has been on occasion coercive, but it can be and often is simply normalizing, helping  the client to reintegrate into the social order and maintaining the necessary emotional stability to function in relation to life’s tasks.
 
The more humanistic type of practice tends to aim in the opposite direction, namely to help the client to stand back from convention and to choose freely how he or she  wants to actualize their potential which may currently be hemmed in by unsuccessful attempts at trying to fit into a conventional social framework. It may help people to break free from unproductive relationships with significant others or to liberate their creativity from humdrum and unfulfilling jobs.
 
In practice, most good, and most integrative psychotherapist would see a positive value in both these  endeavours; to help someone to  have the social skills and emotional stability to play their part as a citizen on the one hand, and to have enough resources to make responsible and rewarding decisions on the other: human beings need both, the capacity for forming and maintaining  meaningful relationships within the social and cultural framework of their society and to  find novel and creative forms of self expression in the face of the challenges of ( post) modernity so that they can carry out tasks which draw on both these capabilities.  
 

 Tullio asks:
 <<In that case, shall we surrender to the irreducible diversity of the two approaches, acknowledging that treating a patient is incomparable with caring for a subject, or shall we understand them as the two terms of a polarity, inside which every therapist can conveniently locate himself or herself according to temperament and preferences? >>

To an extent, as Paul and especially John, have already observed, it is the client’s need which should determine  what therapeutic tasks  need to be undertaken, and the nature of the task will to a large measure determine the method or approach used by the therapist at  a particular point in the evolution of the treatment. To an extent most therapists will be more interested in or more skilled at  a particular way of working – more or less scientifically or more or less artistically. If the therapist is self aware and responsible, such preferences will be reflected in the  kind of  client groups a therapist chooses to work with, which clients he or she refers on to a colleague, more skilled in the empirically validated treatment recommended by any national or international guidelines or protocols insofar as these exist, are relevant or trustworthy.  Integrative therapists may be more versatile and able to function competently over a wider range of treatment modalities and approaches than  so called ‘pure form therapists’, but this is a matter for scientific research to decide, where  therapist orientation is  matched with client outcome…

Tullio Carere, 27  January 2006

Dear Allan,
I am very happy that you make the points below:

<< I agree that the object of psychotherapy research should be, as you put it, “real therapy.” I gather, though (based on past listserv posts), that you do not consider time-limited, protocol-guided therapy provided in the context of a research study to fit that description. If I’m correct in this understanding (and I apologize in advance if I have misconstrued you), then this is perplexingly dismissive of the powerful effects such therapies have been repeatedly demonstrated to have (as well as of the “reality” of the therapeutic encounters I have experienced in doing such therapies). It would also deprive us of excellent sources of the data that I think interests both of us the most: live, meaningful interactions between therapist and client.>>

To begin with, for the First Law of DAP (Discussions among Psychotherapists), your belief in  "the powerful effects such therapies have been repeatedly demonstrated to have" can be matched against the belief of others that the effect of time-limited, protocol-guided therapies is almost irrelevant. Consider, for instance, the results of Luborsky et al's 2002 mega-analysis (meta-meta-analysis). Comparing active treatments, these authors found a non significant effect size of .20 based on 17 meta-analyses, which further shrank to .12 when corrected for researcher allegiance (see also Messer 2001, Messer & Wampold 2002). Secondly, most efficacy studies are based on a set of assumptions (namely, that psychological symptoms are highly malleable, discrete, and relatively independent of long-standing personality processes, that the primary focus of treatment can be readily identified, that the elements of efficacious treatment are dissociable and additive, that these techniques can be implemented in a relatively brief span as prescribed in a manual), assumptions that are not theory-neutral - if theory-neutrality ever exists - but theory-specific of the behaviorism of the 1960s and 1970s. Most of these assumptions are empirically testable, and many of them have either never been adequately tested or have been empirically falsified to one degree or another (Westen et al. 2004). You cannot expect that a process-oriented therapist takes such studies in great consideration.

Real therapy , to me, is what really happens in the relationship between a patient and a therapist, not what the therapist believes to happen as a consequence of his/her allegiance to a theory or a protocol.
But you are well aware of the difference:

<< Relatedly, I am also perplexed by your suggestion of an equivalence between recordings of therapy sessions, and post-session questionnaires. From an empirical perspective, research on training of therapists in motivational interviewing (the area with which I am most familiar) has shown that the gap between what therapists think they are doing, and what recordings show them to have been doing, is rather substantial (especially with regard to expressed empathy). From a psychoanalytic perspective, this should hardly be surprising: no matter how well-analyzed, therapists have their defenses, and their own assessment of what has happened and what they have done in a session should reliably be expected to be distorted in various ways. For access to the rich intersubjectivity of therapeutic process, it seems to me that there can be no substitute for recording of sessions .>>

Does audio- or video- recording permit us to understand what really happens in a therapy? Yes and no, in my view -  more no than yes. Too often have I seen videotapes of therapists proudly showing them in the conviction that everybody should see what they see -  namely, the efficacy of their method -  whereas what I usually see is different to totally different from what they see (not truer, just different). Tapes don't record meanings, just behaviors whose meaning has to be interpreted - and of course the meanings change according to the theory of the interpreter. If you let go of the idea that a tape as such shows the reality of a session, and accept that all you have is a material that must be interpreted according to a theory that will be extolled by some and rejected by others, your enthusiasm for such material could rather fall off, especially if you consider that its processing is extremely time-consuming.
 
In this state of affairs, you might consider the convenience of post session questionnaires vs. recordings. For instance, the questionnaire that we have devised in our small research group asks the patients to rate on a 7-point scale the session outcome and 15 items describing typical session experiences, like "I felt understood", or "I have seen alternatives to my usual behavior" on two columns (respectively, "This is what happened in the session", "This is what I expected in the session"). The questionnaire does not yields numbers to sum to other numbers to make statistics (a game you can play, yet of poor relevance), because the ratings are very context-dependent (a short discussion of the questionnaire at the beginning of the next session is mandatory -  it takes very little time and generally is very useful). It is a simple and efficacious tool to monitor and document the process, in the perspective of George's Local clinical scientist (to be dialectically balanced with the Local clinical artist). Much more practical and economical than any recording, as far as I know. And, last but not least, it heals the rift between practice and research, in the spirit of Freud's Junktim.

Tyler Carpenter, 28 January 2006

For me I suspect that I am less interested clinically in what divides psychotherapists. People make distinctions by nature and may argue over  their respective validity. I find I'm more interested in integrating what I  know of what is known, in the patient and what they present for help with.  In this respect I find my self drawing on a lot about humans that present  itself in the context and conditions I am faced with. Because my patients  are currently typically seriously disturbed sex offenders, this requires an  integration of medicine-criminology-religion-developmental  psychopathology-culture. I see no distinctions between  medicine-meaning-treatment-science, except for the purposes of discussion  with others or articulating to myself what seems to be intuitively true and  clinically effective, or requires more investigation and thought together  with the patient and the context of treaters and security. To me to be  therapeutic is simply to say I got the mix right this time with this person.  I don't think that I'm idiosyncratic in this approach, for by the canons of  our respective professions and the nature of who we work with, I suspect we  make the distinctions which our patients present us with for treatment in  the settings we choose to work. Or said another way, I think any well  trained clinician who undertakes to treat psychotic and character disordered  criminals in a correctional context in which the realities of getting a  favourable result (and preventing tragic and fatal ones) dictates that we  take meaning, context, level of systems, empirical knowledge, and medicine  seriously or not work successfully with those folks. Deviations from such an  "integration" seem to me to be more about experience. In this light physics,  chemistry, brain science, sociology, anthropology, religion, psychology,  etc. all have their place and can be articulated in those meaningful moments  and periods when we and our patients can breathe "aha" as the elements come  together in the therapeutic ebb and flow.  When we work this way, severity becomes less severe and more treatable. More  like a difficult problem in the process of becoming a less difficult one. If  one perseverates and is rigid in ones thinking, the question of the extent  to which this stuckness is state or trait, reflective of  damage-development-context (or most likely an admixture) drives the moment  and the therapeutic response. To split such things into  meaning-medicine-technique, except for the purposes of teaching or  discussion, is to miss a complete understanding of the entire phenomenon at  hand. It's a little like hardening the categories, when in fact that is the  problem to be understood and developed and processed in the moment. Why make  such a moment projective identification-cognitive distortion-perseveration,  when the solution is to standback and address the issue in one of the  numerous ways the patient, environment and tools might address?!  As to our relationship to doctors, that division seems to be less distinct  to me as the practice seems more consumer driven and multi-disciplinary. To  me some behavior and cognitive therapy seems more like some types of  medicine, but when I reflect further or consult another practitioner or  reflect on all that is happening in my consult with my doctor, it seems  that he is drawing on a wider understanding of therapeutics where there is  much overlap in what he and I think that the problem is.

Zuckoff Allan, 29 January 2006

Dear Tullio,

It seems to me that, if “integration” means anything when it comes to the methodology of psychotherapy research, it must involve finding some common ground between “process-oriented” and ”outcomes-oriented” perspectives. While I am far from an uncritical proponent of controlled psychotherapy outcomes research, and I believe that questions about what the cumulative evidence shows thus far are of great importance, your dismissal of this entire body of research as “almost irrelevant” does not, I think, bode well for the project of integration. 

But let us stay, as you prefer, within the realm of process research. You write:

<<Real therapy, to me, is what really happens in the relationship between a patient and a therapist, not what the therapist believes to happen as a consequence of his/her allegiance to a theory or a protocol.>> 

Here we are in complete agreement. Which makes the critical question: how can we best research, and thus understand, “what really happens in the relationship between a patient and a therapist”? Your claim is that recordings of sessions are less valuable for this purpose than I believe, due to the inevitable conflict of interpretations.

<<Tapes don't record meanings, just behaviors whose meaning has to be interpreted - and of course the meanings change according to the theory of the interpreter. If you let go of the idea that a tape as such shows the reality of a session, and accept that all you have is a material that must be interpreted according to a theory that will be extolled by some and rejected by others, your enthusiasm for such material could rather fall off…>>  

This, I would argue, is not only wrong, but highly ironic and (if it were true) ultimately destructive of any meaningful research process. The position you articulate would leave us all trapped in the hermeneutic circle—and thus forced in every case to insist that any one construal of meaning is “not truer, just different” from another. The irony comes from the fact that, by claiming that “behaviors” have no inherent meaning, you are echoing a key (and mistaken) element of the behaviorist position you otherwise reject. The destructiveness derives from the fact that, like all post-structural positions, yours fetches up in relativism and the death of truth.  

Fortunately, one need not be a positivist to escape this trap. Merleau-Ponty showed us how: phenomena (including behavior) are both autochthonously organized (and thus inherently meaningful) and intrinsically ambiguous (and thus open to multiple interpretations). Varying perspectives may be more or less accurate—but some are truer than others, and it is possible (and, if research is to be something other than an endless circle, necessary) to adjudicate between them.

Thus, the problem of recordings does not lie in either their multivocity or their capturing of only a part of the “reality” of a session—but rather, in finding (one or more) methods that can allow them to speak their truth (which is, of course, not “the whole truth” but one part thereof). The method I have used begins with the phenomenological reduction—impossible to complete, yet vital to undertake. I have no doubt that other methods could be viable, as well. 

I believe that the approach I am pointing towards speaks to your own concern about interpretations of therapeutic process being contaminated by the theoretical (and other) biases of those who offer them as demonstrations of their therapy’s power. At the same time, it shares the one virtue of controlled outcomes research that I most admire: it allows for the possibility of falsification of claims of efficacy through public (i.e., intersubjective) evaluation, which is as close as we can come to true objectivity in this realm. Post-session questionnaires, while of some interest, cannot come close either to revealing the richness of therapeutic process, or to putting one’s claims for the power of one’s form of therapy to the test.  

Tullio Carere, 29 January 2006

Dear Allan, you write:

<<It seems to me that, if “integration” means anything when it comes to the methodology of psychotherapy research, it must involve finding some common ground between “process-oriented” and ”outcomes-oriented” perspectives. While I am far from an uncritical proponent of controlled psychotherapy outcomes research, and I believe that questions about what the cumulative evidence shows thus far are of great importance, your dismissal of this entire body of research as “almost irrelevant” does not, I think, bode well for the project of integration.>>

I strongly endorse a dialectic between "process-oriented" and "procedure-oriented" perspectives (though I don't share your enthusiasm for most efficacy studies so far). I do not dismiss an "entire body of research as 'almost irrelevant'", but others do. Some are enthusiastic of that sort of research, others dismiss it (both on the base of robust empirical data: First Law of DaP). Empirical research is necessary, and just because it is necessary it must be criticized (as Westen does) for the way it has been done so far, with so many unjustified and unwarranted assumptions and biases. Above all, I agree with Westen that empirical research should return to real therapy as a natural laboratory in the first place, in order to draw from the observation of real processes the hypotheses to put to test (as opposite to the "Popperian" trend in empirical research, which only emphasizes hypotheses testing), with a much more balanced mix of observation and experiment. I personally believe that empirical research in psychotherapy should be much more of the correlational, and much less of the experimental type.

<<… the critical question: how can we best research, and thus understand, “what really happens in the relationship between a patient and a therapist”? Your claim is that recordings of sessions are less valuable for this purpose than I believe, due to the inevitable conflict of interpretations… This, I would argue, is not only wrong, but highly ironic and (if it were true) ultimately destructive of any meaningful research process. The position you articulate would leave us all trapped in the hermeneutic circle—and thus forced in every case to insist that any one construal of meaning is “not truer, just different” from another. The irony comes from the fact that, by claiming that “behaviors” have no inherent meaning, you are echoing a key (and mistaken) element of the behaviorist position you otherwise reject. The destructiveness derives from the fact that, like all post-structural positions, yours fetches up in relativism and the death of truth.    Fortunately, one need not be a positivist to escape this trap. Merleau-Ponty showed us how: phenomena (including behavior) are both autochthonously organized (and thus inherently meaningful) and intrinsically ambiguous (and thus open to multiple interpretations). Varying perspectives may be more or less accurate—but some are truer than others, and it is possible (and, if research is to be something other than an endless circle, necessary) to adjudicate between them.    Thus, the problem of recordings does not lie in either their multivocity or their capturing of only a part of the “reality” of a session—but rather, in finding (one or more) methods that can allow them to speak their truth (which is, of course, not “the whole truth” but one part thereof). The method I have used begins with the phenomenological reduction—impossible to complete, yet vital to undertake. I have no doubt that other methods could be viable, as well. >>

 I surely am an adversary of scientism, i.e. the belief that science is the ultimate key to crack open the mysteries of life and existence. All scientific enterprise is based on some indemonstrable belief or subjective choice (even mathematic, as Goedel saw and showed). The death of truth is rather a consequence of the hubris that claims that truth can be objectively known. All objective knowledge is the result of some epistemological choices of the subject (which the subject is usually not aware of). This awareness, though, does not make of me a post-modernist relativist. On one hand, this makes me try to recoup the dialectic of the subject and the object wherever it gets lost (in positive sciences it usually does) -  which means that I always try to uncover the hidden presuppositions, choices and beliefs behind any "objective" knowledge. On the other, I don't believe that we are fatally trapped inside our subjective points of view - or hopelessly conditioned by the conditions of our lives. To the contrary, the liberation of the subject from whatever traps or conditions his or her existence is to me the very goal of any psychotherapeutic effort, from the shamans on. Bion's formula "freedom from memory and desire" epitomizes well this basic thrust, and the phenomenological reduction is an important aspect of this freedom -  at least its first step. I am glad to read that your method "begins" with it. You must be aware, though, that it is not enough to begin with it. To become aware of all one's presuppositions, judgments and expectations, and to suspend them continuously, is a very hard discipline, and I would not say that it is the bread and butter of most of those who devote themselves to empirical research -  who therefore quite often remain stuck with their unsuspended and uncriticized presuppositions. But maybe we could agree on this point: science has a good chance of not corrupting into scientism to the extent that the scientist practices a good enough epoché from the start to the end of his or her work.

<<I believe that the approach I am pointing towards speaks to your own concern about interpretations of therapeutic process being contaminated by the theoretical (and other) biases of those who offer them as demonstrations of their therapy’s power. At the same time, it shares the one virtue of controlled outcomes research that I most admire: it allows for the possibility of falsification of claims of efficacy through public (i.e., intersubjective) evaluation, which is as close as we can come to true objectivity in this realm. Post-session questionnaires, while of some interest, cannot come close either to revealing the richness of therapeutic process, or to putting one’s claims for the power of one’s form of therapy to the test.>>  

I don't admire most controlled outcome research for the too many unwarranted assumptions on which it is based. But I do believe that empirical (above all correlational) research can be done in a much more critical and useful way. For instance I admire the work of Stern's group (the Boston Change Process Study Group) on audiotaped transcripts, in which they illustrate how much " sloppiness" (fuzzy intentionalizing, unpredictability, improvisation, variation, and redundancy) generates unpredictable and potentially creative elements that contribute to psychotherapeutic change. I think the Dodo bird would appreciate that his (her?) verdict receives one more empirical support. Post-session questionnaires might be less useful for such purposes, but I value them a lot as precious tools for monitoring and documenting the process at disposal of the local scientist. There is a great deal of unpredictability in the psychotherapeutic process, and I believe it is an " inherent property of intersubjective systems" (as the BCPSG puts it) in spite of those who believe in manualized treatments. If this is the case, let the therapy go its own way, but let us produce objective material (questionnaires are literally objects that can be intersubjectively examined, like audiotaped transcripts) to document the process.  

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