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