(Editor's Note) George
Stricker had the good idea of forwarding to the SEPI
list a contribution on another list by Larry
Beutler, some key points of which are the ones that
follow: "Scholarly reviews of research by those
within the broadly based psychotherapy research
perspective have long held that the psychotherapy
relationship, patient variables, and other
non-technical factors, are more highly related to
outcome than the specific procedures and theoretical
model employed by the therapist…The low percentage
of variance contributed by differences in the model
and procedure used has been the basis for the Do-do
Bird verdict---all psychotherapies obtain
essentially equivalent results, a finding that keeps
being repeated in the preponderance of meta-analytic
reviews… It is fair to conclude that the
correlations between qualities of the therapeutic
relationship and outcome are almost always higher
than the relationship between type of therapy
applied and outcome--i.e., the relationship accounts
for more of the variance than what the therapist
does from a theory of change perspective." This
started a debate in which mainly two positions were
confronted. In one, as represented by George
Stricker, "The Do-do bird challenge is to find
differential effectiveness and, by doing so, get
beyond common factors as the basis of all
therapeutic change." An alternative way would be not
to get beyond common factors in search of
differential effectiveness, but on the contrary to
look right there for the basis of all therapeutic
change. The debate highlighted that these two
positions are not to be thought as mutually
exclusive, but rather as complementary.
George Stricker, 5 June 2000
Larry Beutler published the following on another list
to which I belong. For those who haven't seen it and
are interested, it presents a very comprehensive and
useful summary of a very important area that has been
part of the SEPI debate many times. I am forwarding it
with Larry's permission.
________________________________________________
Jeff Lohr has raised a very important question about
the causal relationship between the therapeutic
alliance and outcome of psychotherapy. Distilled,
Jeff's comment connotes some concern with two issues:
(1) that the "therapeutic relationship/alliance" is
touted as being more strongly related to outcome than
the specific things that a therapist does or the
particular model of therapy used, and (2) that is is
assumed that the therapeutic relationship/alliance is
causally related to outcome. Jeff wonders about the
empirical evidence for these two assumptions.
The assumption that the relationship is a more
powerful contributor to therapeutic outcome than the
procedures used by the therapist is a common
assumption among those who identify themselves with
"Psychotherapy Research" and this position is
represented among the membership of SPR (the Society
for Psychotherapy Research, International). Jeff's
comment, and the responses to it, remind me, however,
that there is a different perspective represented
among those who largely identify themselves with a
specific, usually behavioral tradition. These
individuals may be inclined to be more closely
affiliated with AABT than with SPR. The latter
viewpoint was expressed reasonably well by Bill
Follette who expressed a lack of confidence in the
research on therapeutic alliance or relationship. He
expressed the view that (1) the measurement of
therapeutic alliance or relationship was confounded
with outcomes, and (2) the role of enhancements to the
therapeutic relationship could be understood as a
process in which the therapist enhanced their
reinforcing power.
In the hope of increasing dialogue on these points,
across the perspectives that differentially
characterize these different scholarly traditions, I'd
like to summarize some of the reasons for the two
assumptions that Jeff initially brought into relief
and in the process to address, through available
research, why Bill's analysis of the relationship as a
reinforcement enhancer does not do justice to the
complexity of the process.
First, let me point out that these two different
traditions, what I will simplistically refer to as
"the psychotherapy research" and "the behavioral
analysis" traditions, often differ very widely in what
they select and focus on as the predictor and
independent variables in treatment research.
Admitedly, this is a simplistic distinction because
there are a lot of overlaps between them, and
frequently there are people who keep their hats in
both camps. But, there are also some very clear
differences between them. I remember David Barlow, for
example, at an APA meeting a year or so ago, pointing
out that in the circles in which he travels, the idea
of "non-specific" effects or the Do-Do Bird verdict
(assumedly related to the supremacy of relationship
factors over technique and model factors) were seldom
mentioned. David's view, I suspect, would be shared by
most of those who identify themselves with "behavioral
research" more than "psychotherapy research". And,
this view leads people, I suspect, to place great
emphasis and faith in the techniques of intervention
and the theoretical model from which it comes. It is
from this tradition that RCT research makes the most
sense and the common assumption is that there are
specific treatments for specific disorders.
While the RCT tradition, and the model of specific
diseases and specific treatments that underlie it,
certainly is conducive to the effort to define
Empirically Supported Treatments initiated by Dave
Barlow through SSCP, psychotherapy researchers of the
SPR tradition are more persuaded by the influence of
variables beyond specific, theory-derived procedures
(e.g., relationship, therapist characteristics, etc.).
Hence, John Norcross's development of a task force
that is complementary to the Division 12 effort and
that is designed to identify "components of the
empirically supported relationship" (Incidentally, I
speak as a member of both the Division 12 and the
Division 29 Task Forces).
David Barlow's experience is very different from mine
and I suspect, from the experiences of many of those
who work within a broadly based "psychotherapy
research" tradition. The assumption of the
pre-eminence of techniques and specifically of
cognitive and behavioral techniques over these
external variables, is one that is often disparaged by
broadly based psychotherapy researchers. These latter
researchers are concerned, in their research, with a
wider range of contributing and correlating variables
than those that derive from a given theory like either
IPT or CT. Their concerns are reflected in the
chapters on Therapist, Client, and Process variables
in the HANDBOOK OF PSYCHOTHERAPY AND BEHAVIOR CHANGE
(Bergin & Garfield, 4th Ed., 1994, Wiley). While
they conduct and have widely contributed to RCT
research studies, psychotherapy researchers of this
ilk are also drawn to methodologies that allow the
study of variables that cannot be randomly assigned,
such as therapist relationship factors, patient and
therapist predisposing variables, personalities, etc.
Some of Ken Howard's naturalistic research as well as
his articulated concerns with the problems of RCT
methodlogies are widely and highly valued among this
group of scholars, probably much more so than they are
among those committed to a theory-specific, and more
particularly, a behavior analysis tradition.
Scholarly reivews of research in this area by those
within the broadly based psychotherapy research
perspective have long held that the psychotherapy
relationship, patient variables, and other
non-technical factors, are more highly related to
outcome than the specific procedures and theoretical
model employed by the therapist. Lambert & Bergin
(1978) expressed this view years ago, and it has not
substantially changed (see Lambert, 1989; 1994;
Lambert & Bergin, 1994; Lambert, et al, 1986).
Lambert & Assay (1992) apportioned the percentage
of variance attributed to various therapist, client,
and treatment factors and reached the conclusion that
client variables are most strongly associated with
outcome, followed by the quality of the therapeutic
relationship (therapeutic alliance, facilitative
relationship, etc.). The use of specific procedures
and models (e.g., CT, IPT, etc.) accounte for less
than 10% of the total outcome in their analysis. This
proportion was similar to that reported in
meta-analyses by (Smith, Glass, & Miller, 1981;
Shapiro & Shapiro, 1984). The low percentage of
variance contributed by differences in the model and
procedure used has, as you know, been the basis for
the Do-Do Bird verdict---all psychotherapies obtain
essentially equivalent results, a finding that keeps
being repeated in the preponderance of meta-analytic
reviews (see Wampold, et al, 1997). Thus, it is fair
to conclude that the correlations between qualities of
the therapeutic relationship and outcome are almost
always higher than the relationship between type of
therapy applied and outcome---i.e., the relationship
accounts for more of the variance than what the
therapist does from a theory of change perspective.
Now the evidence for a causal relationship between
relationship and outcome is a little less clear as
Jeff has pointed out. Before it can be addressed
adequately, Bill's concerns with the measurement of
therapeutic alliance must be addressed. He observed
that some items in relationship questionnaires often
ask the rater (patient or therapist or clinician) if
the client's goals are being achieved or if they are
pleased with the way things are going. There has been
much written about this apparent confound, but four
points can be made: First, there are many measures of
the therapeutic alliance, by various names, many of
which do not include this confound (see Greenberg
& Pinsof, 1986) but results seem quite independent
of the specific measure used. Second, these measures
are highly intercorrelated, frequently to the point of
approximating their own reliability indices (Tichenor
& Hill, 1987; Salvio, et al, 1992). Third (and
there are several studies of this, but I can't bring
the specific references to mind, so I'll use our own
data), it makes little difference whether the
relationship items that seem to reflect outcomes are
excluded from the scales or not. Recently we submitted
a study of the sequence among three classes of
predictors--patient variables, therapy procedures, and
matching variables--on two outcomes (therapeutic
alliance and symptomatic change), and subsequently,
the causal chain when relationship was inserted as one
of the predictors . We were critiqued because our
measure of alliance (an independent observer rating on
the HAQ) included five (5) items that were confounded
with outcome. We eliminated these items and correlated
the scales using part-whole correlations, obtaining
correlations above .80, not bad for a scale that has
interrater reliabilities that are much lower than
this, often. We are now looking to see if the use of
the non-contaminated scale changes the pattern of
relationships obtained, but I doubt it.
Finally, when measured as part of the therapeutic
relationship, questions about outcome are in the
nature of asking the respondent to reflect back and
assess the degree of their progress. This single point
in time (retrospective) measure of "outcome" would
never be accepted in today's climate as a measure of
improvement. In fact, one of the major critiques of
the CR study was that the authors measured outcomes
only at the end of treatment. The problem is that when
measured in this way, there is only a very low
correlation of these ratings and pre-post measures
(Beutler, Wakefield, & Williams, 1994; Beutler
& Hamblin, 1986). To compensate, the CR authors
developed a retrospective pre-post measure (a
procedure that our group had recommended in 1981).
I've recently seen a study, the reference to which I
can't pull up, that suggested that even these scores
did not correlate well with actual pre-post
measurement. In fact, these retrospective measures
only correlate well with current state, leading to the
conclusion that they are measures of "satisfaction"
not measures of improvement. Thus, it is highly
unlikely that the use of such items seriously
contaminates pre-post measures of outcome.
Assuming that I have dispatched the issue of
contamination raised by Bill Follette for the moment,
let us look at the evidence for a causal chain between
patient variables, through treatment procedures and
relationships, to outcome. That evidence is relatively
sparse, but two lines do suggest a causal chain that
links relationship quality to outcome. First is a
plethora of studies that have used lagged correlations
between early developed relationships and outcomes. In
Vanderbilt I, Strupp observed that the therapeutic
relationship as measured before the 10th session
predicted distal outcomes (This was reported in an SPR
presentation---I don't know the published reference)
and this was consistent with the early findings of
Luborsky in the Penn Psychotherapy Project, in which
ratings at session #3 were quite higly predictive of
distal outcomes, sometimes 2 years later (Luborsky et
al, 1991). (Both Les Greenberg and Adam Horvath have
confirmed these findings, I believe, though I don't
have a specific reference). In the study that I
mentioned in an earlier paragraph, we also looked at
early alliance (first five sessions) and distal
outcome, obtaining a value of .36 after the influence
of initial patient variables and therapy procedures
were factored out through MR procedures.
In a Structural Equation Modeling procedure that
compared a simple relationship --> outcome versus
relationship + patient + matching variables -->
outcome model, we found that both models were
consistent with the data, but that process variables
added variation that was independent of the therapy
procedures used (Beutler, Clarkin, & Bongar,
2000). As you know, SEM doesn't care about the
temporal sequence of variables. That has to be built
into the model. So, SEM could easily confirm that a
given data set is consistent with the view that distal
outcome produced an earlier measured relationship
event, if the investigator was foolish enough to
propose this model to test.
As a final point, consider the repeated observation
that different therapies often are distinguished by a
particular pattern of developing the therapeutic
relationship (Rounsaville, et al, 1987). I will send,
to those who are interested, a series of graphs from a
current comparison of three types of psychotherapy in
the course of the development of the therapeutic
alliance. These graphs are from an RCT study of CT and
two new therapies, one focused explicitly on trying to
develop a therapeutic alliance that is devoid of
patient resistance and the other that matches specific
treatments to specific non-diagnostic qualities of the
patient. To summarize, the growth of the relationship
differs quite distinctively. This morning, I got back
a components analysis of these differences. I don't
have it all digested yet, but it is clear that a given
HAQ score in the three different therapies is
reflecting a very different experience for each, and
that the pattern of components over time is very
different from therapy to therapy. While the overall
correlation between early alliance and distal outcome,
and even follow-up, remains in the .30-.40 range,
therapies are distinguished by what items load in the
ratings of alliance and the pattern of development is
very different from therapy to therapy.
If all a good relationship did was improve the
therapist's reinforcing power, I would think that the
NT (relationship-based) therapy would have been the
best on symptom measures, since the alliance was best
in this treatment, but this was not the case. CT and
PT produced better effects on several indices in this
sample of co-morbid stimulant dependent and depressed
patients.
References
Bergin, A.E., & Lambert, M.J. (l978). The
evaluation of psychotherapeutic outcomes. In S.L.
Garfield & A.E. Bergin (Eds.), Handbook of
psychotherapy and behavior change: An empirical
analysis (pp. 139-190). New York: John Wiley.
Beutler, L. E., Clarkin, J. F., & Bongar, B.
(2000). Guidelines for the systematic treatment of the
depressed patient. New York: Oxford University Press.
Beutler, L.E., & Hamblin, D.L. (1986).
Individual outcome measures of internal change:
Methodological considerations. Journal of Consulting
and Clinical Psychology, 54, 48-53. (special edition)
Greenberg, L.S., & Pinsof, W.M. (l986). The
psychotherapeutic process: A research handbook. New
York: Guilford.
Lambert, M. J. (1989). The individual therapist's
contribution to psychotherapy process and outcome.
Clinical Psychology Review, 9, 469-485.
Lambert, M. J. (1994). Use of psychological tests
for outcome assessment. In. M. E. Maruish (Ed.) The
use of psychological testing for treatment planning
and outcome assessment. Hillsdale, NJ: Lawrence
Erlbaum Associates, Publishers.
Lambert, M. J., & Bergin, A. E. (1994). The
effectiveness of psychotherapy. In A. E. Bergin &
S. L. Garfield (Eds.), Handbook of psychotherapy and
behavior change (4th ed., pp. 143ˆ189). New York:
Wiley.
Lambert, M. J., Shapiro, D. A., & Bergin, A. E.
(1986). The effectiveness of psychotherapy. In S. L.
Garfield & A. E. Bergin (Eds.) Handbook of
psychotherapy and behavior change, 3rd ed. (pp.
157-211). New York: John Wiley and Sons.
Rounsaville, B. J., Chevron, E. S., Prusoff, B. A.,
Elkin, I., Imber, S., Sotsky, S., & Watkins, J.
(1987). The relation between specific and general
dimensions of the psychotherapy process in
interpersonal psychotherapy of depression. Journal of
Consulting and Clinical Psychology, 55, 379-384.
Salvio, M., Beutler, L. E., Engle, D., & Wood,
J. M. (1992). The strength of therapeutic alliance in
three treatments for depression. Psychotherapy
Research, 2, 31-36.
Shapiro, D.A., & Shapiro, D. (l982).
Meta-analysis of comparative therapy outcome studies:
A replication and refinement. Psychological Bulletin,
92, 58l-604.
Smith, M. L. Glass, G. V., & Miller, T. I.
(1980). The benefits of psychotherapy. Baltimore: The
Johns Hopkins University Press.
Tichenor, V., & Hill, C. E. (1989). A comparison
of six measures of working alliance. Psychotherapy,
26, 195-199.
Wampold, B. E., Mondin, G. W., Moody, M., Stich, F.,
Benson, K., & Ahn, H. (1997). A meta-analysis of
outcome studies comparing bona fide psychotherapies:
Empirically, "All must have prizes." Psychological
Bulletin, 122, 203-215.
Tullio Carere, 12 June 2000
I realize that a taxonomic approach (a map of the
common psychotherapy factors organized in a
comprehensive whole) has not much sex appeal, but
could at least the Do-Do Bird verdict (thank you
George for reminding us of it) be a firm point of
departure? If we assume, according to this virdict, a
large supremacy of relationship factors over technique
and model factors as predictive of change, we are
faced with a most basic question: What makes a
therapeutic relation out of an ordinary, every-day
relation?
One first possible answer would be the following:
Therapeutic factors are embedded in ordinary,
every-day relations, and a therapeutic relation is one
led by a therapist who (a) knows which are these basic
factors, and (b) knows how to activate and employ them
moment by moment in the relation with her client. One
second possible answer would be instead: As what
happens in ordinary relations is that everybody tries
to impose his theory or world view onto the other (and
so called therapists are no different in this
respect), real therapy only begins when one suspends
his theoretical and personal preconceptions and
persuades the other to do the same--thanks to this
suspension a space opens where negotiations, new
experience and genuine search can happen.
The two answers are not, to me, mutually ewclusive
(but the second comes first, and breaks the ground to
the first). Any other responses to the Do-Do Bird
challenge?
Alan Javel, 13 June 2000
Differences are indeed easier to see, probably
because they are the most glaring. To understand the
similarities, one would need to look very closely at
technique. In my opinion, what we do, how we do it,
and when we do it are the basic building blocks of any
relationship, therapeutic ones included. I am always
disturbed by the idea that my theoretical orientation,
whatever it may be, may merely be window dressing, a
small part of the actual business of the therapy which
has been defined by my office environment, my
verbalizations, and my silences.
Hilde Rapp, 13 June 2000
Alas, the dodo bird was rendered down to illuminate
the dark nights of explorers of uncharted
territories...
If it weren't for the differences in viewpoint
between our two eyes, our picture of the world would
be rather one dimensional.
Similarly, to my way of working, much of the power of
psychotherapy derives from those aspects of our
practice which are different from the ways in which
odinary relating takes place. In my personal
experience, meta-conversations are singularly
unpopular among my loved ones, yet they are the
deadlock breakers in my therapeutic work.
I have no trouble with enthuisiastic clebrations of
'vive la differe/ance' – bowing to Derrida slightly
–but I suppose as a Sepi-ite I see my task more as
endeavouring to understand differences, and to
understand whether they are merely interesting,
trivial or therapeutically significant – in the way of
Clarkin and Frances' differential therapeutics. We are
way off being able to map systematic differential
applications of therapeutic techniques to distinct
clinical populations with measurable different
problems in ways which yield demonstrable
solutions. Even if none of these ways of
describing our art, science and craft chimes well with
particular value base which puts the clients meaning
making in the centre, there still is a burden of proof
on us within Sepi that we do more than provide
human understnding and the equivalent of pastoral
care.
This is were I like the postmodern stance: a modest
approach to mapping some differences which seem to us
clinically important, intellectually non trivial, and
at least describable if not measurable in some
coherent and communicable way: to start with the
particular, the human, the subtle small gestures of
human relating – and where we feel bold enough to look
for the larger social paterns that connect...
Sepi is to my mind about generating interesting
hypotheses about change factors and other things, to
find really interesting ways of talking about the
complexities of the human condition, and to bandy
together with our colleages in SPR to devise
intelligent ways of finding out what we do well that
helps clients to put their life back together and to
get on better with others...
How about the phoenix verdict?
Michael Basseches, 13 June 2000
I must have missed or forgotten the original do-do
bird challenge--Could you, George, or someone, remind
me.
But to answer to the question Tullio poses would be
to agree that "therapeutic factors are embedded in
ordinary, every-day relations". I would add though
that psychologically destructive factors are also
embedded in ordinary every-day relations. Clients
often come to us with a hope to remedy some of the
damage that their relationships have done to them, or
ways in which their development has been constrained
by those relationships, but with a repertoire (of
action/meaning-making schemes) that may provoke others
to repeat the damage that has been done. Therefore, I
view no goal as more important in therapist training
than learning how to create relationships which
minimize the destructive factors, as well as to
optimize the therapeutic factors in "ordinary
every-day relations". You refer to the latter when you
say--"a therapeutic relation is one led by a therapist
who (a) knows which are these basic factors, and (b)
knows how to activate and employ them moment by moment
in the relation with her client," but as you know from
what I have written, I think the former
dimension--effort and skill at avoiding harm or
oppression (Leston Havens calls it "predation") is
equally important.
Your second answer -- suspending theoretical and
personal preconceptions -- may be one way of
attempting to avoid harming clients within therapy
relationships, but I have trouble endorsing that one
because I think (as you do, I believe) that it is
impossible to do so completely, and also, because
there are many other skills required in this effort as
well. Thank you for pushing/inviting us to keep
addressing such crucial questions in the service of
psychotherapy integration.
George Stricker, 14 June 2000
Dear Mike,
I'll just respond to your question to me, and reserve
any other comments for another time. In the 1970s
Luborsky wrote a summary of psychotherapy research,
found overwhelming evidence for effectiveness, but no
evidence for differential effectiveness among
orientations. His article was subtitled "All have won
and all must have prizes," from Alice in Wonderland,
hence the term Do-do bird effect. The Do-do bird
challenge is to find differential effectiveness and,
by doing so, get beyond common factors as the basis of
all therapeutic change. That is exactly what is being
attempted by people such as Beutler, who are looking
for therapist-patient matching keys to how to work
most effectively, but I am not impressed by the depth
of their findings (even though I keep hoping that
there will be something there).
Michael Basseches, 14 June 2000
Thanks, George. So would the following qualify as a
response to the challenge or is it a side-stepping of
the challenge?
While common factors may be one set of significant
contributors to therapeutic change, and aspects of
therapist-patient match may be another set of
contributors, differential effectiveness may be found
in variations in therapists' intellectual and
interpersonal abilities (to which effective therapist
training can hopefully contribute) to understand and
work through a less than optimal match and to
transform it into a successful therapeutic
relationship.
I believe that this set of of
perspective/ability/training/experience factors
represents a third very important set of contributors
to therapeutic effectiveness (to which SEPI has, and
should continue to attend). I think both Tullio and my
posts were efforts to address this issue. Does it
indeed address the Do-do challenge.?
David A Shapiro, 14 June 2000
Actually it was Rosensweig in the 1930's who first
applied the Dodo metaphor to psychotherapy research.
Subsequently, Bill Stiles, Robert Elliott and I took
up the theme in our 1986 American Psychologist
article, "Are all psychotherapies equivalent?".
George Stricker, 16 June 2000
To Mike Basseches:
I don't think that the set of factors you mention
(and I agree with your sense of their importance)
speaks to the Dodo bird issue, because those factors
do not differentiate the orientations and the final
verdict, all must have prizes, still holds. However,
whether or not you read the Dodo as I do, you still
are presenting a hypothesis, and it would take
empirical data to address the Dodo and provide
contrary evidence.
To David Shapiro:
I wasn't aware of Rosenzweig's use of the term, but
the Luborsky review was in the early 70s and preceded
your article. When it comes to the provenance of a
term like Dodo bird, I don't think we can be sure of
anyone other than Lewis Carroll.
Tullio Carere, 17 June 2000
George Stricker wrote: "The Do-do bird challenge is
to find differential effectiveness and, by doing so,
get beyond common factors as the basis of all
therapeutic change."
This is surely a way of reading the Do-do issue.
Another way, in my view no less legitimate, is not to
get beyond common factors in search of differential
effectiveness, but on the contrary to stay within the
common factors, and look there for the basis of all
therapeutic change. I dare say that the latter reading
is even more legitimate, because if "All have won and
all must have prizes", the outcome cannot depend on
the method-specific factors in the first place, but it
must relate primarily to those factors that are common
across all orientations.
The standpoint, then, radically shifts. The focus is
no more on a theory of the mind, as in most
psychotherapeutic traditions, but on the therapeutic
relation, and specifically on the question: what is
therapeutic in a therapeutic relation? (and its twin
question: what is pathogenic in a pathogenic
relation?). Do we need empirical research to know that
an abusive relation is pathogenic? I don't think so.
By the same token, we should not need empirical
research to know that theoretical abuse is what turns
a would-be therapeutic relation into a pathogenic one.
But could a therapist who clings to his theory or
manual not be abusive? I don't see how he could. This
means that manual- or theory-driven treatments are
fine for research aims, but they are no real therapy.
On the contrary, they are surely abusive in the long
run. It follows that the first and foremost common
factor to any therapy is the freedom from theory,
which does not mean to have no theories--it means not
to be conditioned by them, that is to be able to
suspend them, to remain in a (relatively) theory-free
space. Which corresponds, besides, to the time-honored
first duty of all therapists: primum non nocere.
Michael Basseches wrote: "Your second answer --
suspending theoretical and personal preconceptions --
may be one way of attempting to avoid harming clients
within therapy relationships, but I have trouble
endorsing that one because I think (as you do, I
believe) that it is impossible to do so completely,
and also, because there are many other skills required
in this effort as well."
The suspension of all theoretical and personal
preconceptions cannot be anywhere near perfection, but
it must be "good enough" to allow at least for the
beginning of a negotiation--how could a negotiation
ever begin if one refuses to yield his/her truths?
(And you are the first among us to alert to
theoretical abuse). We may then be even more
ambitious, if we don't content ourselves with
negotiations but we want to know what one person
really needs (beyond all theories, techniques, and
constructions).
If the suspension of all theoretical and personal
preconceptions - the phenomenological epoché -
is the basic common factor of all therapies worth the
name, it is also the base from which to start, and to
which always return, to investigate on all other
common factors. Failing this, we would only have
theories and would be prisoners of them (which has in
fact happened to the psychotherapy schools--couldn't
SEPI be a remedy?).
Hilde Rapp wrote: "How about the phoenix verdict?"
That's another bird. As you know, the phoenix lives
very long, and goes into fire only at the end of its
long life. Psychotherapy is still very young. There
will come a time for the phoenix, but it seems the
Do-do is our bird now.
George Stricker, 17 June 2000
I think Tullio and I were saying something very
similar, but from different perspectives. I spoke
about the Dodo challenge (to find differential
effects) and he about the Dodo effect (the importance
of common factors). Two sides of the same coin, as I
see it. I also agree on the problems of manualizing
that which should be more responsive to idiographic
occurrences. However, there are two points on which we
disagree, I think. The first is the value of empirical
data. There are many things which are obvious (e.g.,
the sun moves around the Earth), but do not stand the
test of investigation. The second is Tullio's
statement "It follows that the first and foremost
common factor to any therapy is the freedom from
theory, which does not mean to have no theories--it
means not to be conditioned by them, that is to be
able to suspend them, to remain in a (relatively)
theory-free space." I think he is speaking about a
wish rather than an empirically verified finding,
especially as it is the case that many therapists are
theory-driven, to the detriment of their work, but
that means that being theory-free clearly is not a
common factor. I think we also have to be aware of the
distinction between the role of theory in
understanding what is happening (critical, in my view)
and its role in determining our interventions
(secondary, again in my view, and I think in Tullio's
as well).
Tullio Carere, 17 June 2000
George Stricker wrote: "I think Tullio and I were
saying something very similar, but from different
perspectives. I spoke about the Dodo challenge (to
find differential effects) and he about the Dodo
effect (the importance of common factors). Two sides
of the same coin, as I see it."
I totally endorse this view. On the one side of the
coin I put theoretical integration (the assimilative
avenue), on the other side the common factors approach
(the accommodative avenue).
George: "I also agree on the problems of manualizing
that which should be more responsive to idiographic
occurrences. However, there are two points on which we
disagree, I think. The first is the value of empirical
data. There are many things which are obvious (e.g.,
the sun moves around the Earth), but do not stand the
test of investigation."
To me this is another coin, or better said the same
coin at another level. On the one side there is
theoretical-empirical science, based on hypothesis
testing; on the other side there is
descriptive-phenomenological science, aimed at the
uncovering of evidence. If this dialectic is lost,
science is lost too.
George: "The second is Tullio's statement "It follows
that the first and foremost common factor to any
therapy is the freedom from theory, which does not
mean to have no theories--it means not to be
conditioned by them, that is to be able to suspend
them, to remain in a (relatively) theory-free space.":
I think he is speaking about a wish rather than an
empirically verified finding, especially as it is the
case that many therapists are theory-driven, to the
detriment of their work, but that means that being
theory-free clearly is not a common factor."
This is right what I meant: when therapists are
theory-driven, it is to the detriment of their work.
Saying that "the first and foremost common factor to
any therapy is the freedom from theory", I meant any
genuine, non theoretically abusive therapy.
George: "I think we also have to be aware of the
distinction between the role of theory in
understanding what is happening (critical, in my view)
and its role in determining our interventions
(secondary, again in my view, and I think in Tullio's
as well)."
My view here is slightly different. Instead of seeing
the role of theory as critical in understanding and
secondary in determining our interventions, I prefer
to balance the theoretical-interpretive moment and the
phenomenological-intuitive one in both.
George Stricker, 17 June 2000
It seems as though Tullio and I have reached
agreement, despite the apparent differences in the
original presentations. There is one point he made
well that I would like to reiterate: "To me this is
another coin, or better said the same coin at another
level. On the one side there is theoretical-empirical
science, based on hypothesis testing; on the other
side there is descriptive-phenomenological science,
aimed at the uncovering of evidence. If this dialectic
is lost, science is lost too." I agree totally,
although I, with Reichenbach, prefer to refer to this
as hypothesis generation and hypothesis testing, and
the dialectic nature of these processes, which Tullio
refers to, is crucial, and there is no need to choose
between them.
Zoltan Gross, 17 June 2000
May was an extraordinary month for me. In the
beginning of May, I attended and presented at the SEPI
Meetings in Washington, D.C. and at the end of the
month I went to the Conference on the Evolution of
Psychotherapy (CEP)in Anaheim, CA. At both meetings,
the presenters talked about psychotherapy in different
languages. They had different conceptions about what
the nature of help was or should be. Underlying these
differences were different assumptions about the task
of psychotherapy. The presenters described what they
thought psychotherapy "looked" like and it looked
different to all of them.
This is not an unusual observation. Minuchin at the
CEP meetings commented on the fact that the diversity
of explanations about the nature of psychotherapy was
both enormous and intelligent. He went on to say that
all of the presenters believed that they were
"effective" therapists, including himself. He also
noted that it is remarkable that so many dedicated and
talented men and women have examined the two person
therapeutic relationship have come up with so many
different explanations about its nature. Furthermore,
he said that regardless of their explanatory
differences, they were all helpful (the Do Do Bird). I
agreed. I saw it with my own eyes. The interviewees
invariably left their fifteen minute sessions
expressing gratitude for the help they received.
The bedlam of voices caused me to think they were
talking about different interpersonal enterprises.
This observation puzzled me. If they were different
kind of relationships, why, then, did all of the
interviewees express the same appreciation for the
different kinds of help they received? The clatter of
explanations had such a dizzying effect on me that I
turned the sound off. The quieting peace that followed
allowed me to look at what these different therapists
were doing with their client/patients, without being
distracted by my confusion about their different
explanatory systems. I was struck by how much alike
they looked.
Of course, the therapists were clearly different in
their personal presentations. Albert Ellis' aggressive
assertiveness was different from Eugene Gendlin's
gentle empathy or Leslie Greenberg's "Santa Claus"
geniality. Yet they were all authoritative and had the
presence and wisdom that comes with years of practice
and teaching. They were all respectful and
comfortable. They were clearly interested in being
helpful. At the beginning of each demonstration, the
presenters gently took care to put their clients at
ease. All of this was done without asking anything in
the way of validational feedback from the interviewee.
At the same time all of the therapists were powerfully
present with their interviewees. They made eye contact
and continually sending nonverbal signals of approval
and understanding to the client/patient. They were all
quiet, warm, nonjudgemental and intuitively empathic,
wanting to have a clear understanding of how the
interviewees experienced their distress. They asked
the interviewee to describe the problem that brought
them to the interview. The therapist asked penetrating
questions until he or she understood the problem the
interviewee about which he/she wanted help. These
questions demonstrated the intelligent interest of the
therapist and conveyed to the client/patient that
she/he was in competent hands. The therapist carefully
proceeded to reframe their interviewee's problem in
his/her own terms. The therapist's restatement of the
problem caused the interviewee to think about his/her
problem in a new way and provided him/her with a way
of thinking about the problem in the therapist's
language. The client/patients were given a new
cognitive perspective on the nature of her/his
distress.
Where else in life can a person get this kind of
undemanding, knowledgeable, good willed attention? I
disagree with Tullio's contention that therapists are
engaged in an "ordinary everyday relationship." They
were engaging in a relationship which I believe is a
Twentieth Century interpersonal invention. It takes
years of clinical practice to become comfortable and
skilled in this kind of relationship. To me the
therapeutic relationship is related to but not
identical with Buber's description of the "I-Thou"
relationship. The similarity of approach by the
therapists I saw is partially responsible for the Do
Do Bird effect. Other variables also operated to
produce the differential effects to which George
Stricker calls our attention.
Three kinds of information will help us escape from
the banality of the Do Do Bird's prizes. We need a
better understanding of the dynamics of dyadic
interaction. None of our current explanations of
dyadic interaction enables us to describe the moment
to moment music of emotional experience that arises
when two people are personally involved with one
another. Related to this, we also need to know much
more about the contribution that the therapist's
person plays in psychotherapy. I look forward to
results John Norcross' commission looking into this
matter. While there is evidence that therapists differ
in their effectiveness, there is no research studying
the role of the therapist's person in the therapeutic
process. That information would provide us with
valuable information about the nature of therapeutic
effectiveness. Finally, more clearly specifying the
goals of therapy will help us to see the differences
in the therapies as well as their similarities. There
is a real difference between therapies that are
devoted to character change and those that seek to
provide relief from the distress of affective
disorders.
Hilde Rapp, 19 June 2000
The 'phoenix verdict' is just an invitation to
consider a paradigm shift – of the sort that would
allow us to consider the Do-do challenge (to do, to
attend to what we do reflectively, and not to become
extinct) and the Dodo verdict (as explained by George)
in the same frame. To suspend and conserve both
perspectives in a meta-frame: what is common and how
is this non trivial – ie distinctive to therapy rather
than any broadly emancipatory activity, and what is
distinctive. Core competencies and specialist
competencies: core competncies which transcend
orientations, and specialist competencies which are
theory, technique, modality or context driven.
As you know Tullio: the bird which comes out of the
fire is the same bird which went in – just with some
of the dross burnt clean in the purifying flame – and
that which was good distilled and fortified...
PS: Let me know if you want me to stop being poet and
mystic and start being craftswoman and scientist – the
philosopher cannot be dispensed with.
Tullio Carere, 21 June 2000