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