|
Editor's
Note In
preparation
for the 2nd
Sepi- Italy
Conference,
held in
Florence from
24 to 26 March
2006, Tullio
Carere asked
the speakers
of the
Conference and
the members of
the Sepi
listserv to
participate in
an on-line
debate. In his
e-mail dated
22 January
2006, Carere
proposed a
series of
questions
which have
been the
starting point
for a rich and
passionate
discussion
among 16
participants
(listed in the
order in which
they
intervened) :
Tullio Carere,
Paul Wachtel,
John Norcross,
George
Stricker,
Allan Zuckoff,
Hilde Rapp,
Tyler
Carpenter
Tullio
Carere, 2 February
2006
Thank
you dear Hilde for
your rich
response, which
reflects your
vision of
psychotherapy as
art and science -
which is also my
vision. Medicine
too is art and
science, but
psychotherapy is
such in a very
special way, given
its kinship with
natural sciences
on one side and
human sciences on
the other. Our
field has not yet
been able to find
a viable
integration
between these two
sides. You
acknowledge that
there are
"different
traditions which
are linked to
different
practices", one
"diagnostically
driven", and the
other of "more
humanistic type".
But the difference
you underscore is
between two
opposite thrusts,
one
adaptive/normalizing,
and the other
actualizing/self-realizing.
If this were the
point, your
observation that
"most good, and
most integrative
psychotherapist
would see a
positive value in
both these
endeavors"
would solve the
problem, and the
integration
between the two
traditions would
already have been
happily realized.
In my view this
unfortunately is
not the case.
As a matter of
fact, there is a
big rift between
the two
sub-fields. Here
is how I describe
the relevant
difference: Those
"diagnostically
driven", as you
fittingly name
them, apply the
simple principle
of diagnosing a
disorder, a
problem, a need,
or a phase, and
prescribing the
(empirically
supported)
procedures to fix
the disorder or
the problem, or to
meet the need or
the phase. This
frame of mind is
commonly called
"medical model",
because it
corresponds to the
medical treatment
as it is
conceptualized in
our time. On the
other side, the
adherents to the
adversarial
perspective, often
called "contextual
model", maintain
"that
psychotherapy is
incompatible with
the medical model
and that
conceptualizing
psychotherapy in
this way distorts
the nature of this
effort" (Wampold,
2001). They
propose as an
alternative a
holistic/contextual
approach, in which
common factors are
emphasized to the
detriment of
procedures (which
are reduced to
mere placebo).
Both sides support
their views with
enormous amounts
of empirical
research; both
sides maintain
that the approach
of their side is
the one that best
meets the needs of
the clients; and
both sides dismiss
the other as
simply wrong if
not harmful. As
Westen put it,
"the intensity of
the acrimony, the
distaste, has
never been so
high."
If we want to come
to terms with this
split, we might
start with a few
things. To begin
with, we should
not deny its
existence. A way
both sides have to
dismiss the other
is to simply deny
their existence as
a partner of a
dialogue or a
negotiation. If
the other does not
exist, why should
we waste our time
with dichotomies
or polarities? It
is pointless.
Secondly, we
should get rid of
the myth of
scientific
neutrality. If X
and the opposite
of X are both
empirically
supported, we
cannot ask
empirical research
to solve the
problem (I am not
saying that
empirical research
is useless, but
only that it
cannot solve this
problem). Thirdly,
it is clear that
no reconciliation
is possible
between the
medical and the
contextual model.
But do we really
need them? They
are both
abstractions far
from everyday
practice. In the "common
sense" model
every therapist
makes use of some
procedures which
they deem useful -
therefore
they are not
contextualist. But
nobody applies
them in a protocol
mode: they use
heuristic,
rule-of-thumb
procedures, and
adapts them to the
present
circumstances -
and every
patient responds
to their
therapist's
procedures
according to the
way they
understand them
and the way they
need them.
Everything happens
out of a great
deal of
improvisation and
"sloppyness".
Therapy works when
there is a good
enough working
alliance, which is
not the result of
protocols, but of
ongoing
negotiations. In
the common sense
perspective there
is room for both
procedures and
context: at this
level integration
is possible,
whereas what we
get from the
protocol-driven
and the contextual
perspective is the
split of the
field.
In the common
sense perspective
it is not so
important to
separate the
procedures from
the context. What
is crucial instead
is to correlate
process and
outcome, i.e. to
understand what
transpires in the
clinical (not the
experimental)
setting that
explains the
progress, or the
lack of progress.
It seems to me
that empirical
research is much
more useful when
it tries to
illuminate this
matter, than when
it claims to prove
or disprove the
efficacy of
procedures
independently of
the context. This
is my response to
my own questions.
Hilde
Rapp, 6 February
2006
Tullio
wrote:
<< You
acknowledge that
there are
"different
traditions which
are linked to
different
practices", one
"diagnostically
driven", and the
other of "more
humanistic
type". But the
difference you
underscore is
between two
opposite
thrusts, one
adaptive/normalizing,
and the other
actualizing/self-realizing.
If this were the
point, your
observation that
"most good, and
most integrative
psychotherapist
would see a
positive value
in both these
endeavors"
would solve the
problem, and the
integration
between the two
traditions would
already have
been happily
realized. In my
view this
unfortunately is
not the case.
As a matter of
fact, there is a
big rift between
the two
sub-fields. Here
is how I
describe the
relevant
difference:
Those
"diagnostically
driven", as you
fittingly name
them, apply the
simple principle
of diagnosing a
disorder, a
problem, a need,
or a phase, and
prescribing the
(empirically
supported)
procedures to
fix the disorder
or the problem,
or to meet the
need or the
phase. This
frame of mind is
commonly called
"medical model",
because it
corresponds to
the medical
treatment as it
is
conceptualized
in our time. On
the other side,
the adherents to
the adversarial
perspective,
often called
"contextual
model", maintain
"that
psychotherapy is
incompatible
with the medical
model and that
conceptualizing
psychotherapy in
this way
distorts the
nature of this
effort"
(Wampold, 2001).
They propose as
an alternative a
holistic/contextual
approach, in
which common
factors are
emphasized to
the detriment of
procedures
(which are
reduced to mere
placebo). Both
sides support
their views with
enormous amounts
of empirical
research; both
sides maintain
that the
approach of
their side is
the one that
best meets the
needs of the
clients; and
both sides
dismiss the
other as simply
wrong if not
harmful. As
Westen put it,
"the intensity
of the acrimony,
the distaste,
has never been
so high." >>
I entirely
agree with you,
Tullio, that the
field at this
present moment
is divided
and that debates
are acrimonious.
However, I
would want to
argue that it is
precisely because
of this situation
that integrative
psychotherapy-
where the emphasis
is on the syllable
–ative- ie an
ongoing process-
is necessary , and
that this
was, indeed, the
stimulus for the
origination of the
‘movement’ for
exploring the
integration of
psychotherapies.
We have had
four recognized
waves, the last
being
accommodative-
assimilative
integration.
I am,
however not
describing the
status quo, but
rather I am
actively and
passionately
pleading for
a fifth wave- as I
believe are you-
which advocates
for meta-
integration.
Meta-
integration
can
accommodate the
historically
existing
differences
because
increasingly
integrative
therapists set
store by and are
skilled in
‘negative
capability’- ie
the capacity to
tolerate paradox,
uncertainty,
contingencies and
ambiguity as
inevitable
properties of
complex living
systems.
With this
comes the
recognition that
any integrative
‘solutions’ will
be local and
specific and are
likely to
relate to
single lines of
conflict. There
are echoes here of
Bion’s dream that
there could be a
grid that would
allow us to
specify a problem
quite precisely-
that we might be
able to formulate
a coherent
question by
means of which to
interrogate
reality. But there
is also the
recognition that
in fact we really
proceed in a much
more random
fashion,
making use
of
unexpected
windows of
opportunity,
leaps of the
imagination, the
availability of
new descriptive
and analytic tools
as information
technology
improves, victims
of the vagaries of
intellectual
fashion and the
vicissitudes of
everyday life as
it presents
populations with
new anxieties, new
challenges
and both
news defenses
( beliefs in
panaceas,
distractions etc)
and new solutions,
real or
imagined.
The new
skill is not so
much the capacity
to deliver
sweeping answers
which unify a
universe of
discourse- this
would be my
‘quarrel’ with Ken
Wilber’s ‘integral
psychology’ as an
attempt at a new
‘theory of
everything’. The
new skill would be
to have a
methodology for
transforming
conflicts between
assertions and
positions by
focusing on common
needs and goals-
perhaps also
common factors-
but more strongly
on common
functions:
What is the
function of the
client’s defenses
or resistances?
How do they
aim to meet the
client’s needs-
and which ones?-
and what are their
priorities in
terms of the
client’s
assumptive world
and value system?
Is it bread or
honor ? As it
were. Echoes of
Maslow would
figure here and
the contemporary
expansion of his
model into a
more
differentiated
hierarchy of needs
in Spiral
Dynamics. It is an
enterprise that is
both modest and
bold.
Tullio wrote:
<<If we
want to come to
terms with this
split, we might
start with a few
things. To begin
with, we should
not deny its
existence>>.
Agreed. We
need to bear the
pain of its
existence and
accept
splitting
and polarization
as a part of the
human condition
and hence also the
professional
landscape, and we
need to endeavor
to understand
the
psychological
pressures which
maintain these
splits and
conflicts.
Tullio
wrote:
<< A
way both sides
have to dismiss
the other is to
simply deny
their existence
as a partner of
a dialogue or a
negotiation. If
the other does
not exist, why
should we waste
our time with
dichotomies or
polarities? It
is pointless.
Secondly, we
should get rid
of the myth of
scientific
neutrality. If X
and the opposite
of X are both
empirically
supported, we
cannot ask
empirical
research to
solve the
problem (I am
not saying that
empirical
research is
useless, but
only that it
cannot solve
this problem).
Thirdly, it is
clear that no
reconciliation
is possible
between the
medical and the
contextual
model. But do we
really need
them? They are
both
abstractions far
from everyday
practice>>.
I am
reading this
as description of
the arguments
advanced in the
split field rather
than as statements
of your position-
I am right in
this? As you
can see from the
previous response,
I entirely agree
that the
problems arises
and is maintained
by the fact that
both positions are
‘abstractions from
practice’.
Tullio
wrote:
<<In
the "common
sense"
model every
therapist makes
use of some
procedures which
they deem useful
-
therefore
they are not
contextualist.
But nobody
applies them in
a protocol mode:
they use
heuristic,
rule-of-thumb
procedures, and
adapts them to
the present
circumstances -
and every
patient responds
to their
therapist's
procedures
according to the
way they
understand them
and the way they
need them.
Everything
happens out of a
great deal of
improvisation
and
"sloppyness".
Therapy works
when there is a
good enough
working
alliance, which
is not the
result of
protocols, but
of ongoing
negotiations. In
the common sense
perspective
there is room
for both
procedures and
context: at this
level
integration is
possible>>
Hhmm…
Yes I agree that
at the pragmatic
level, as
confirmed by Lisa
Najavits’
research,
senior
and/or successful
practitioners tend
to be responsive
to clients needs
and hence use
whatever heuristic
approach
moves the
client on with
respect to insight
and desired
change.
Experienced
therapists
from widely
different
orientations are
therefore more
similar to each
other with respect
to their practice
and their ‘theory
in use’, what ever
their ‘espoused
theory’, than they
are, by and large,
to
their more
junior colleagues
from
the same
theoretical
orientation. It
seems much more
important to ask
in the first
instance : what do
you do? What does
your praxis look
like? What are you
aiming to achieve,
what are your
goals? and
only then to
ask for theory
informed
explanations of
these praxis
choices…
Tullio wrote:
<< whereas
what we get from
the
protocol-driven
and the
contextual
perspective is
the split of the
field>>
I raise this
in my chapter
about research-
the protocol
driven perspective
tends to
have its
home in the
research
community, in that
it is – for many-
a favored
vehicle for
formulating and
testing
researchable
questions in a
reliable and
consistent way.
We need ask
population focused
questions: Does
this approach work
at all and if so
how does it
compare to its
competitors? Does
this intervention
really work? For
whom does it work?
Does the change
last? Obviously,
unless there is as
much
standardization as
possible there is
no possibility to
compare what
therapist A does
with client
A to what
therapist B does
with client B.
I don’t
believe there is a
serious
expectation that
therapy in natural
environments
should be carried
out in such
formalised ways.
Once there is
evidence that a
particular
protocol does seem
to deliver the
desired clinical
change reliably,
it would seem
foolish, in a cash
strapped service,
not to offer such
treatments. The
issue then becomes
what to do
with clients or
types of clients
who do not seem to
respond to
generally
effective
approaches
designed to
target
the kinds of
problems
these
clients bring.
Most
researchers and
clinicians
are modest
enough to
recognize that
such clients exist
and that other
forms alternative
help
may be
needed. Even
though advocates
for a particular
approach may not
see it as part of
their brief to
find out
what needs
to be done,
the
extraordinary
changes in which
cognitive
behaviour therapy
is now
conceptualized and
delivered,
including both
relationship and
mindfulness
focused
approaches,
testifies to the
openness of
researchers and
practitioners to
exploring new ways
of working in
order to reach
clients” that
other beers don’t
reach”.
Once
there is
evidence that
something does
work in principle,
we want to ask
process
questions
concerning
how (
perhaps even why?)
it might do so.
Within ‘hard
science’
approaches this is
done through
experimental
methods which
focus on
observable and
measurable
variables.
So called
‘contextual’
approaches do not
( or should I say
should not?) make
any claims
that the
‘soft’ science
variables which
underlie
their
practice are (
with some
exceptions)
researchable by
certain
‘hard science’
means and they
should not be
expected to
produce equivalent
outcomes.
This is not
to say that they
should be exempt
from the public
health related
question as to
whether their
approach
is
capable of
producing reliable
clinical
change, ie works
in principle and
works for
particular
populations,
and whether it
works as well as
its competitors,
or whether it has
a competitive
advantage in
relation to
specific
populations, and
should therefore
be publicly
funded.
Historically,
contextual
approaches have
struggling with
descriptive
case histories and
analytical
formulations which
address how or why
certain kinds of
therapist
behaviours might
successfully
address certain
kind of client
behaviours, such
as defenses,
thought
/feeling/behaviour
patterns
(schemas) and how
unconscious
pressures and
relationships
might play a role
in both. They have
largely done so
anecdotally, but
in a way which is
recognized as a
sizable body of
expert clinical
opinion capable of
guiding practice.
There are good
reasons for these
differences in
epistemology and
methodology which
I will come back
to below.
Tullio
wrote:
<<In
the common sense
perspective it
is not so
important to
separate the
procedures from
the context.
What is crucial
instead is to
correlate
process and
outcome, i.e. to
understand what
transpires in
the clinical
(not the
experimental)
setting that
explains the
progress, or the
lack of
progress. It
seems to me that
empirical
research is much
more useful when
it tries to
illuminate this
matter, than
when it claims
to prove or
disprove the
efficacy of
procedures
independently of
the context.
This is my
response to my
own questions>>.
I suppose the
‘common sense’
perspective is
actually still
an ‘uncommon
sense’
perspective.
I agree, see
above, that it is
a ‘both-and’
scenario, where
the real challenge
for my
proposed
meta-integrative
approach is one of
humility and
cooperation in the
face of the
complexity of the
human condition
and the marvelous
achievements
of the moral
imagination we are
capable of on a
good day and the
awesome depths of
depravity we seem
to be able to sink
to on a fearsome
day.
We
need people who
will examine the
outer landscape of
how human beings
negotiate their
conflicting needs
through social
contracts of one
sort or another,
and for this
behaviour
focused ‘
normalizing’
approaches are
extremely useful.
We equally need
people who plumb
the inner
landscape of
how we
attribute
meaning to
our passions,
dreams and fears.
The kinds of
measurement
that are fit
for calibrating a
psychic plumb line
that reaches
into the depths of
meaning making are
not the same as
those fit
for
regulating
socially adaptive
behaviour by means
of
guidelines
that map our
social skills.
However,
social skills
without the
attribution of
meaning are empty,
mechanical
and
soulless, and
efforts
after meaning
without the social
skills to share
them with others,
leave people
isolated, without
role or
relationships
on the
margins of the
social world.
Only by each
bringing to the
table the
best we can offer
by way of tools
for enquiry, ways
of reaching out to
lonely,
frightened, lost,
confused and
deeply troubled
fellow human
beings, and ways
of satisfying our
social
institutions that
taxpayers money is
invested ethically
and effectively,
can we move
forward : in other
words only by
integrating the
fragments of what
we know and know
how to do well,
can we serve
humanity as
psychotherapists
and mental health
professionals…
This means loosing
our fear both of
healthy
competition and of
accountable
co-operation…
Ken
Benau, 7
February 2006
Hilde
wrote:
<<However,
social skills
without the
attribution of
meaning are
empty,
mechanical
and
soulless, and
efforts
after meaning
without the
social skills
to share them
with others,
leave
people
isolated,
without role
or
relationships
on the
margins of the
social
world>>.
I
simply want to
say, bravo! Having
worked with many
developmentally
challenged
children and
adults who have
deficits in social
skills, but
usually lack an
appreciation for
the reason, i.e.
one that gives
them
meaning/purpose,
to apply said
taught skills in
the first
place. The
"depth" folks and
the "behavioral
skills" folks have
much to teach each
other, if we can
only listen.
As
a serendipitous
aside: an
Asperger adult
client of mine
recently ended a
session telling me
why he believes
there is a link
(in
Asperger's/high
functioning
Autism) between
deficits in mirror
neuron functioning
and executive
functions... I
don't know his
theory yet, but
he's obviously
been doing his
reading and I am
very curious... So
I should add, if
we can listen to
our clients, too.
Hilde
Rapp, 7 February
2006
Dear
Ken,
Thank
you for your
feedback. I
also have some
experience of
working with
people suffering
from neurological
or developmental
deficits and
learning
difficulties. I am
struck by the
level of insight
some people
do have into their
difficulties and
how imaginatively
they talk about
them by
making use
of metaphors where
they lack access
to – or the
capacity to
understand-
relevant
scientific
research.
We can often
help by amplifying
their ‘naïve
theory’ with
research, where we
ourselves know
any. This
seems to
help clients make
sense of their
difficulty better.
It helps them to
normalize and
accept it and it
encourages them to
co-develop and
practice relevant
coping
mechanisms with
the therapist.
From
a practical
perspective even a
‘superstitional’
pseudo theory can
function like this
because any
explanation that
makes subjective
sense to the
client will lessen
anxiety and hence
lower the
threshold for
responding to
therapeutic
help…
I
tend to translate
into appropriate
language that a
client can
understand
something to the
effect of “
Given what is
going on in your
brain/ nervous
system/endocrine
system…etc
it is to be
expected that you
should have this
difficulty. It is
a normal
consequence of
your impairment.
Let us look
in detail at
how this makes
your life
difficult and let
us work out
together what you
might do to
make it easier to
function
despite your
impairment…
This
can be learning to
breathe, speak in
a particular
rhythm to overcome
dysarthria and
speech problems
which seriously
get in the way of
communication. Or
it can mean
helping a client
learn to
understand
the anxiety
reducing effect of
gaze avoidance in
intimate
situations (
Michael Argyle
studied this in
Oxford in the
seventies),
and to help a
client to use gaze
avoidance with
awareness by
learning to
say to an
interlocutor: I am
sorry I have
difficulty
looking you
in the eye while
I talk to
you because
it makes me
loose my
thread…. And so
forth…
All
this
develops out
of the
therapist’s deep
respect for the
client’s wish and
need to make
meaning of their
difficulties
through listening
‘deeply’ as Rogers
once put it. Our
task is to
accept,
amplify,
clarify, and
transform
what the client
knows about
themselves and
then to add, as
necessary, new
skills and
understanding
which enrich the
client’s
repertoire.
It
helps enormously
if we understand
enough about
normal and
abnormal human
development and
physiology and
the effect of
adverse
events and
environments on
both. To know
something about
1) normal
responses to
abnormal
circumstances or
2) normal
sequelae of
abnormal
development, or
conversely, 3)
abnormal (
neurotic or
psychotic)
responses to
normal
environments,
and of course,
4)
developmentally
normal responses
to normal
situations
is very
helpful. It
empowers the
therapist to
convey to
clients that
their experience
is
understandable
and expected in
the light of
research. This
provides a
sound
basis for
helping people
to drop
developmentally
superseded
defenses and to
develop more age
appropriate
ones, to
overcome
abnormal
defenses to’
objectively’ non
threatening
stimuli , and or
to
explore ways of
using the
plasticity of
the brain to
bypass a
current loss or
distortion of
function.
Here
it is the
‘contextualists’,
especially
within
psychoanalysis and
constructivism
have rekindled the
passionate
interest Freud had
in understanding
the links between
the physiological
( phi) and the
psychic ( psy) as
he explored this
and theorized this
in his project for
a scientific
psychology
by
participating in
neuroscientific
research. In
addition,
especially
analysts, have
been revisiting
and working
collaboratively
with
academic
experimental
cognitive and
social
developmental
psychology, while
cognitive
behaviour
therapists
have from
the outset been
grounded in
academic
research
that focuses on
the connections
between beliefs,
attitudes,
emotions and
behaviour. The
difference seems
to be largely one
of language, what
is impulsivity in
one quarter
becomes lack of
mentalisation in
an other and what
might be time out
and thought
stopping in one
tradition might
become reflective
functioning in
another…
It
is all out there
for the taking
if we
are not too
frightened to
leave our
silos…
Tullio Carere, 9
February 2006
Tyler
Carpenter wrote:
<< To me
to be
therapeutic is
simply to say I
got the mix
right this time
with this
person.
........
To split
such things into
meaning-medicine-technique,
except for the
purposes of
teaching or
discussion,
is to miss a
complete
understanding of
the entire
phenomenon at
hand.>>
I agree, Tyler. It
seems to me that
you apply a common
sense
model (like
most of us?). The
problem with this
model is that the
mix
that looks
right to you might
look wrong or
arbitrary to
others. If
we don't rely
on empirically
supported
procedures
(possibly because
our faith in
the external
validity of ESP is
too weak), how do
we know that
our mix is right?
If the validity of
our work is not
guaranteed by
the strict
adherence to some
e.s. protocols (a
guarantee
widely accepted
these days), do we
have any
alternative to
producing objective
material, like
post-session
questionnaires or
session recordings,
to monitor and
document our
work?
Tyler Carpenter,
9 February 2006
I
suspect that we
all share more
than a little
"horse sense" in
our
work, Tullio,
though I greatly
admire the clarity
and particularity
that you
and Hilde
bring to your
explanations of
what you do.
For
me in the prison,
where I work and
play, there was a
period not a
little like
an initiation
where one is
tested and left on
one's own a lot.
With so much
at stake you are
watched carefully
for your ability
to manage
what comes
your way and to
others. A gradual
accretion of
successful
public experiences
gives you
credibility and
things get easier
and you're
trusted and
called on for the
tough stuff. In
other words, one
can believe
whatever one
wants about what
one does (and
others can think
what they like
about you),
but how things
turn out is what
makes the
difference.
Perhaps that
is the prison
version of EST.
There are a lot of
terms for pseudo
courage
and ability
in this
sub-culture. The
issue is not what
you call it or
where
you said it
came from, but
what you can do. I
have to say that I
thought I
was pretty
good before I went
to prison. Now I
know, and so do
others, what I
can and can't
do. The best
complement I ever
got was in a Super
Max when
the Captain,
who had heard
others refer to me
as "Doc", asked me
if I was one.
I told him I
was one and he
reacted with
vehement disbelief
for a few
weeks until I
showed him my
license. I asked
him why he didn't
believe I was
one and he
said simply "You
don't talk like
one." In these
places it boils
down to the
basics. I
once watched while
a consultant
(chosen by some
experts new to
prison work)
who spoke all the
right behavioral
stuff came to help
out a
stalemate in
maximum
segregation. I
have an M.A. in
general-experimental
psychology and
understand what
operational
analysis supposed
to accomplish.
The consultant
used models that
came from the
literature that
completely
failed to
take into account
factors that drove
the behavior and
undergirded
the system.
The result went
nowhere. Whatever
you call it and
wherever it
comes from,
it won't work if
you don't know how
to apply it. This
is the
great lesson
of places like
prisons. People
come from outside
to apply what
works one
place without
understanding the
context. John
Gall's
"Systemantics" is
a marvelous
example of the
importance of
thinking about
context and what
goes in it
and how that might
change what
happens in strange
and chaotic
ways. Part
of the problem is
to go beyond
articulating the
divisions and take
the leap into
talking about how
meaning is
simultaneously
diagnostic
and biological
and dynamic and
contextualized in
systems. The only
SEPI presenter
I ever talked with
who would directly
talk about the
more molecular
levels of
system and
their interaction
with things like
meds
was Bernie
Beitman. When he
talked about how
people needed to
want to change
for meds to
work I was
floored. Now after
working with
dangerous and
psychotic character
disorders for
years at a
stretch, I see how
the seams to the
work can be
brought by the
therapist's models
and that when
transmuting experience
in the dyad with a
treatment team and
multiple models
and multiple
staffs reduces
symptoms and
brings
satisfaction, that
's the
kind of
result that goes
beyond models and
arguments. Our
team had a
marvelous time
talking about a
stalker whose
vulnerabilities
were ego syntonic.
How
do you talk
and think about
target for meds
when there is
critical
disagreement on
meaning between
patient and team
and context is
variable, but
necessary to
get therapeutic
leverage?!
I'd
love to have a
fraction of the
protected time I
had as a junior PI
at Harvard
now as a clinician
in the trenches,
but am too busy
putting out
the fires
that are brought
my
way.
Tullio
Carere, 20
February 2006
Hilde
wrote (on
February 6):
<<The
new skill is
not so much
the capacity
to deliver
sweeping
answers which
unify a
universe of
discourse-
this would be
my ‘quarrel’
with Ken
Wilber’s
‘integral
psychology’ as
an attempt at
a new ‘theory
of
everything’.
The new skill
would be to
have a
methodology
for
transforming
conflicts
between
assertions and
positions by
focusing on
common needs
and goals-
perhaps also
common
factors- but
more strongly
on common
functions:
What is the
function of
the client’s
defenses or
resistances?
How do they
aim to meet
the client’s
needs- and
which ones? -
and what are
their
priorities in
terms of the
client’s
assumptive
world and
value system?
Is it bread or
honor? as it
were. Echoes
of Maslow
would figure
here and the
contemporary
expansion of
his model into
a more
differentiated
hierarchy of
needs in
Spiral
Dynamics. It
is an
enterprise
that is both
modest and
bold.>>
I agree, Hilde.
Every theory of
everything is
bound to clash
with other
theories of
everything, as
religions have
always done and
still do. An
"integral
psychology" has
more to do with
integralism than
with
integration, in
my view. And I
strongly endorse
your idea that
in order to
transform
conflicts
between theories
we should focus
on common needs,
goals and
functions. My
own formulation
of the same idea
is that in order
to transform
theoretical
conflicts we are
bound to move to
a non
theoretical
ground - and
this ground is
the common
ground where we
find all common
needs, goals and
functions. This
implies that we
don't need a
theory of the
common ground -
if I put forth a
theory of it,
somebody else
will put forth
another theory
that will be no
less empirically
supported than
mine, and there
we are again.
This is where
the common sense
comes in.
You
write:
<<I
suppose the
‘common sense’
perspective is
actually still
an ‘uncommon
sense’
perspective>>.
Yes, common
sense is still
quite uncommon.
But we can try
to make it a
little more
common, if we
understand how
badly we need
it. Many believe
today that
psychotherapy
integration can
only happen on
the ground of
empirical
(especially
experimental)
research. I
believe that
this belief is
the main reason
of the big rift
in our field.
Besides, it
encourages all
schools to
empirically
support their
theories, and in
the end the Dodo
bird is the one
who wins. The
faith in
empirical
research, as
applied to
psychotherapy,
does not seem to
have any
integrative
effect on our
field. To the
contrary. If we
hope to be able
to communicate
among us,
shouldn't we
return to the
commonalities
(to the things
themselves, as
Husserl put it),
i.e. to the
basics of
experience? And
how do we get to
these
commonalities,
if not on the
ground of common
sense, that is
the sense that
is common to
everybody who is
willing to use
it? We all can
use our
abilities of
intuition and
argumentation
(nous kai
dianoia, as the
Greek knew
well), but the
correct use of
these requires a
disciplined
mind, a mind
that disciplines
itself by means
of
epoché,
or suspension of
memory and
desire, or
similar ways. Of
course this is
quite
unzeitgemaessig
for our
undisciplined
Zeitgeist. Yet,
controlled
clinical trials
and statistic
processing of
data are poor
substitutes for
disciplined
minds. Maybe a
growing number
of therapists
and researchers
will realize
that. If this
happens, common
sense will be a
little less
uncommon in our
field.
Hilde
Rapp, 20
February 2006
Dear
Tullio,
Thank
you and a general
reply in haste
with apologies:
John Norcross was
quoted in the UK
guardian
this week (
have you seen it
John?) with a sort
of reply by Andrew
Samuels, a
prominent Jungian-
in a piece which
argued, as you
have done, Tullio,
that there is
practically a war
on between lets
say the
psychoanalytic and
person centered
imagination and
the
empirically
researched
approaches to
treatment.
Although
probably not meant
to be
inflammatory,
Andrew argued that
some people need a
more
sophisticated,
‘nuanced’, as he
called it,
approach.
I
think this is
unfortunate
because its draws
false
distinctions, to
which Paul
Salkovkis would
justifiable rise
with passion. Both
sides are
sophisticated and
nuanced, both
sides set store by
‘epoche’ ( I do
too, and strongly-
although I also
humbly think we
are relatively bad
at suspending
preconceptions as
a biological
species – at least
we should aim
for it!)
both sides are
well schooled in
philosophy of mind
and science- and
both sides are
passionately
committed to
bettering the lot
of suffering
people.
That
is the common
ground position.
So
why the near war?
In
the seventies
there was a fierce
Methodenstreit- a
battle of methods
between the ‘human
sciences (
Geisteswissenschaften)
grounded in
hermeneutics ,
lead by the
Frankfurt School (
TW Adorno) on one
side and Karl
Popper as the
representative of
the positivist
camp on the
other
( contributions
were collected by
Erst Topitsch in
German)…We should
really get round
to recognizing
that we do
precisely neither
have a theory
of
everything nor a
corresponding
epistemology for
everything that is
coherent and
systematic. We
can
understand facets
in detail and we
can
understand
the relationship
between these
facets in general,
ie we can have a
metatheory
which helps us to
locate and relate
facets of
understanding to
one another.
It
is surely positive
that we can and do
have vigorous,
passionate, and on
occasion, even
rigorous debates
about which shoe
fits which foot
and which glass
slipper does not.
My
only regret is
that we do,
all too
often get carried
away by our
passions to the
extent that we
forget to be
respectful. Then
we argue ad
hominem
instead of
ad argumentum or
factum - and
we forget that not
everyone speaks
Latin or
statistics
or
Latino-Greek
nosology and
psychiatric
classification or
post modern
contextualist
jargon – or dare I
say it- English!.
So we should
be polite and
translate.
We
need to humanize
our dialogue
without loosing
our commitment to
the original
Platonic purpose
of dialogue-
namely to arrive
at approximations
to the
truth(s).
We
also need to
humanise the
dialogue in the
sense of
remembering that
much of the
quarrels are not
about truth(s)
or facts,
but about values.
Values,
by definition are
not strictly
speaking , based
on rational
decision making or
indeed empirical
validation- as
both researchers
and modelers know
only too well.
They are about
life choices,
about preferences,
about ethics and
aesthetics.
These
preferences will
never be unified-
and in that sense
Andrew Samuels in
right- our
tastes will always
be nuanced and
there will always
be people who
prefer one style
of therapeutic
interaction to
another.
There
is – in my view-
however far too
little serious
dialogue
about the basis on
which decisions
are made about
funding
psychological
services and
what
epistemologies
and models ,
methodologies and
methods
can be
agreed to be
mutually
acceptable to
demonstrate that
services deliver
the outcomes they
are set up
to bring about (
Health Technology
Assessment,
in the UK) .
Here we get into
health promotion,
social inclusion,
ethics, health
economics and
models of
needs assessment
and so forth :
what the public
may demand/want
may not actually
meet their
assessed need ( I
have early lung
cancer \and I want
a fag, may
meet a
psychological need
but contravene a
medical one)
and what services
want to supply may
meet demand, but
not need ( I want
to sell cigarettes
because I have a
pile of them, but
people actually
need food).
This no
longer has much to
do with theories
of psychotherapy-
although it does
have something to
do with models of
(wo)man,
philosophy of
science, and the
mind and
morals…and it also
has to do with
research by
medical
anthropologists ,
sociologists and
social
psychologists…
Paul
Wachtel, 20
February 2006
Hi
Tullio and Hilde,
Looking forward to
seeing you both
soon.
Tullio, I think we
will find, when we
get into the
in-person
discussions, that,
as we might
expect, there are
both agreements
and disagreements
(which is, of
course, what makes
the whole thing
interesting).
I think one of my
biggest
disagreements is
that you have, in
my view, much too
much faith in the
"disciplined"
mind. As I
think I stated in
a previous
exchange on the
sepi listserve on
Bion, "without
memory or desires"
seems to me like with
self-deception.
But apart from the
specifically
Bionian version, I
simply don't think
we can be nearly
as disciplined as
you give us credit
for. I think
the entire
scientific
enterprise
dovetails exactly
with Freud's main
message (even if
Freud himself --
perhaps
illustrating the
very point --
didn't always heed
this) -- that our
capacity for
self-deception,
for seeing what it
is convenient to
see, is utterly
enormous.
The controls of
systematic
empirical research
are not a perfect
solution, not a
panacea, and it is
certainly true
that if we take
the findings of
any particular
study (or even
line of study) as
gospel, this is
just another form
of
self-deception.
But I still think
that the controls
of systematic
empirical research
are very
substantially
better than the
"discipline” the
lone clinician can
muster. So,
although I myself
have not been
primarily an
empirical
researcher (and
hence, as you
might imagine, I
don't believe that
is the only path
to knowledge) I do
believe that
disciplined and
serious critical
and integrative
thought (which, I
guess, is what my
own contributions
largely consist of
-- when I'm doing
well) cannot be
very useful unless
it pays very
serious and
careful
attention to
systematic
empirical
research.
Reversing your
sentence, I would
say that
"disciplined
minds" can be poor
substitutes for
controlled
clinical trials
and statistical
processing of data
-- although I
don't think
controlled
clinical trials
are always the
best way to
investigate
particular
questions and
indeed, are often
used (and set up)
in highly
tendentious and
misleading
ways.
Critical thought
is always
needed. I'm
certainly not
advocating giving
up our minds for
our statistical
programs.
But I think you
are too cavalier
and dismissive
toward empirical
data. The
dodo verdict
either reflects a
real phenomenon
(in which case we
need to take it
seriously in our
thinking) or
poorly conceived
and biased studies
(in which case we
need to examine
the sources of
potential bias and
do better
studies), but it
is not a
reflection of the
inadequacy of
empirical research
per se.
I'm
all for common
sense. But unaided
it often
doesn't get us
very far.
Common sense tells
us the world is
flat, the sun
revolves around
the earth,
etc. Quantum
theory, relativity
theory go against
"common
sense."
Sometimes, it is
the non-intuitive,
the idea or
finding that challenges
our intuitive
sense of things
that is what we
need to be open
to.
If you're saying
that we need to be
wary of the
arrogance of the
"empirical" or
"scientific" finding
(also to be put in
quotes) I am 100
percent with
you. But if
we substitute for
that the arrogance
of our clinical
observations, or
intuition, or
common sense, then
we have gained
very little.
But enough. It's
hard to do this at
a distance (I'm
not of the
generation of
instant messaging)
and it always
sounds more
adversarial when
put this
way. When we
see each other in
a few weeks, and
can talk about it
over a cappuccino,
then we
will make progress
in the
conversation.
Paul
Wachtel, 20
February 2006
Just
read Hilde's
contribution
after sending
the reply to
Tullio. I
think in many
ways Hilde is
making similar
points to the
ones I
made. So
when the three
of us (and John,
and whomever
else) have that
cappuccino, my
guess is that
(a) we will have
a very
interesting
conversation
[actually, that
one's a
no-brainer --
because the people
aren't); [b)
that we may well
find that our
particular
points of
agreement or
disagreement are
different than
they seem on the
email
exchange.
I say this
because I assume
(I think
correctly, that
however the
conversation has
been tilting in
response to
previous tilts
[ad infinitum?]
, we all in fact
agree that there
is no single
path to truth
and that
multiple
perspectives are
essential.
So what will get
really
interesting is
when we try to
go past that
bland generality
(which also, of
course, happens
to be at the
same time a
profound truth)
and see just
where and why we
do depart.
David
Allen, 21
February 2006
Tullio,
Hilde, Paul:
Don't
we all agree
that we need
both empirical
research to
reduce the
biases of
clinical
observations AND
clinical
observations to
reduce the
inherent
limitations of
our ability to
measure
psychological
constructs in
empirical
research?
Not only
scientists but
patients
responding to
psychological
measurement can
deceive
themselves as
well as others.
The two methods
of discovery
compliment one
another to my
mind; another
example of
"both-and"
thinking rather
than "either-or"
thinking.
In the same
dialectical
vein, of
course
every "theory of
everything"
generates a
competing theory
of
everything.
The two of them
are then
reconciled,
generating yet
another
thesis-antithesis-synthesis.
This is how
knowledge grows
as we get closer
and closer to
truth. I
think this is an
argument in
favour
of the
genesis of
metatheories,
not against it.
Andre
Marquis, 22
February 2006
Dear
Paul, Tullio,
Hilde, David,
and everyone
else:
To
begin, I’d like
to briefly
introduce myself
to the SEPI
members and
express my
heartfelt thanks
for a community
that seems so
genuinely
devoted to
non-parochial
dialogue, in
contrast to
acrimonious
debate. I join
this discussion
as assistant
professor of
counseling and
human
development at
the University
of Rochester, a
mental health
counselor
fortunate to
have been
mentored under
Michael Mahoney,
a founding
member of
Integral
Institute, and
one of my
primary
interests is
exploring
various avenues
of psychotherapy
integration.
I have been
reading the
discussions on
the SEPI
listserv for the
past four
months,
wondering when I
might chime in;
when Hilde
mentioned
Wilber’s
Integral theory,
I recognized my
cue, which is
also pertinent
to the current
dialogue on the
role of
empiricism and
evidence-based
practice. It
does seem clear
that the vast
majority of
SEPIites are
deeply
sympathetic to
the current
emphasis on
accountability
and recognize
the need to
ground our
practice in
evidence. It is
necessary then,
even if
elementary, to
delineate what
forms of inquiry
and evidence
constitutes
legitimate forms
of data. As
Gerald Davidson
recently wrote http://www.apa.org/divisions/div12/homepage.html <http://www.apa.org/divisions/div12/homepage.html> ,
let’s bear in
mind that
“empiricism”
derives from
“based upon
experience.” To
limit our
evidence to
strictly
controlled
randomized
clinical trials
seems limiting
indeed. I am
certainly not
opposed
across-the-boards
to the EST
research
protocols, but
the stringent
exclusion
criteria, lack
of clarity
regarding
reporting
therapist
characteristics,
problems with
strict adherence
to manual-driven
therapy, and
less-than-optimal
follow-up
reporting (to
name a few
criticisms; EST
critiques
abound: Andrews,
2000; Carroll
& Nuro,
2002; Messer,
2001; Miller,
1998; Persons,
1991; Seligman,
1995; Slife,
2004; Slife
& Gannt,
1999; Weisz et
al., 2000;
Westen et al.
2004; Westen
& Morrison,
2001) suggest
that a plurality
of complementary
methodologies
would more
comprehensively
inform our
clinical work.
And here is one
of the many
controversies
where I view the
AQAL model
(All-Quadrant,
All-Levels,
all-lines,
all-types,
all-states) of
integral theory
being
particularly
informative.
Wilber’s
quadratic model
(I’ll confine
myself here to
quadratic
issues)
represents the
interior and
exterior of any
occasion,
individual,
event, etc. That
occasion,
individual,
event etc. can
also be viewed
as an isolated
occasion or
contextualized
within larger
systems. So, the
inside and
outside of both
an
individual/occasion
and the larger
systems/collectives
in which that
individual/occasion
emerges yields 4
distinct
perspectives
from which to
view and
conceptualize
any phenomenon.
Reminiscent of
the parable of
the blind men
arguing about
what the
elephant
actually was, it
seems to me that
systematically
integrating
methodologies
from at least
those 4
perspectives
would
mutually-inform
each perspective
and generally
enrich the
communicative
exchange between
researchers and
clinicians. A
simplified
example of
methodologies
from each of the
4 quadrants
appears below:
(I just realized
that a figure
loses its
formatting via
email so it's
more of a list;
imagine the
intersection of
two axes:
interior/exterior
and
individual/system)
The
Four Quadrants
and
Methodologies
Appropriate to
Psychotherapy
Individual
from Interior:
(Subjectivity):
Phenomenological
analysis of
clients’
experiences of
therapy (Rogers,
Bugental, May)
Individual
from Exterior:
(Objectivity):
Empirical
investigations –
from
EST/RCT
methodologies to
other
“objective”
approaches such
as
neuroscience
(Damasio,
Siegel, LeDoux)
System
from Interior:
(Interobjectivity):
Systemic
analyses
(including
videotaped
sessions) ala
Greenberg’s
(1999) intensive
observation,
measurement,
and analyses of
concrete-change
performances; as
well how
client
and therapist
engagement
evolves
(social-autopoetically);
any
other
external
analyses of
systems such as
of environmental
consequences
that
impact client
outcomes
System
from
Exterior:
(Intersubjectivity):
Interpretive
inquiry in
general
(Riouer,
Gadamer, Giorgi)
including
hermeneutic
investigations
of
the
intersubjectivity/in-betweeness/fit
of client and
therapist
(Stolorow
et al)
An integral
approach to
psychotherapy
research calls
for an
integration of
research
methodologies –
honoring the
values and
limits of each
approach – and
anticipates that
a coherently
organized
pluralism of
inquiries (an
“integral
methodological
pluralism”) will
help advance our
understanding of
psychotherapy
process and
outcome far more
than one
narrowly-defined
form of
empiricism will.
Although Hilde
Rapp’s writings
are among my
very favorite on
the SEPI
listserv, I
don’t understand
the nature of
her “quarrel”
with Wilber. As
someone deeply
familiar with
his work, I
don’t consider
it accurate to
say his project
is to “unify a
universe of
discourse” so
much as it is to
provide a
conceptual
scaffolding
(AQAL) with
which many of
the parochial
and acrimonious
debates can be
transformed into
mutually-enriching
dialogues,
hopefully
facilitating
both humility in
each camp’s
claims to total
knowledge and a
heightened
curiosity about
how other
perspectives can
enrich their
own. For
example,
Wilber’s
quadratic model
nicely
assimilates
Hilde’s “four
simple
distinctions to
map the field –
each of which
connects into a
particular
tradition of
enquiry” (see
below). In a
similar manner,
many approaches
that appear
irreconcilable
(medical and
contextual) are,
from the
meta-perspective
of integral
theory, not only
reconcilable,
but mutually
enriching.
The
Four Quadrants
and Hilde Rapp’s
“four simple
distinctions to
map the
field
– each of which
connects into a
particular
tradition of
enquiry”
Individual
from Interior:
“I.
exploring
subjective
experience”
Individual
from Exterior: “
III. Examining
and measuring
bio-social
determinants”
System
from Interior:
“II.
Exploring
cultural
patterns of
meaning
making”
System
from
Exterior:
“IV.
Investigating
the effects of
social-political-environmental-economic
regulation of
society”
Hopefully the
"figures" of the
four quadrants
reveal that an
integral
approach (and
there is not
just one
approach to
integral; it is
a broad
framework
capable of
assimilating and
accommodating
tremendous
diversity)
transcend
dichotomous
positions. No
one perspective
or methodology
is inherently
privileged over
others in all
cases. Yes, one
approach may be
more appropriate
than another
based upon
developmental
issues or a host
of other factors
(quadrants,
lines, states,
types, etc.),
but no
“pure-form”
approach or
methodology
hegemonically
dominates within
the integral
metatheory.
I also do not
think that all
meta-theories
necessarily
clash with or
contradict other
meta-theories.
Wilber’s
integral
metatheory
(2000a; 2000b)
and Mahoney’s
constructive
metatheory
(2004) are
illustrative of
this. Both
Wilber and
Mahoney are not
only sympathetic
to each other’s
work, but
Mahoney and I
(2002) have
written together
on “Integral
Constructivism”,
though that
article was far
from a genuine
integration of
those two
metatheories.
Also
fundamentally
commensurable
with those two
metatheoretical
approaches is
the
Transtheoretical
approach
(Prochaska,
DiClemente,
Norcross) which
is something
akin to another
metatheoretical
approach.
To address very
briefly Tullio’s
initial question
regarding why
psychotherapists
are so much
divided, I want
to suggest that
the very
boundaries that
separate and
divide
therapists also
connect them
simultaneously.
Strict empirical
methods will
never disclose
the qualities of
lived-experience
or what makes a
life worth
living, just as
phenomenology
will never
reveal the
neurobiological
underpinnings of
our experience.
Am I naïve,
or isn’t it
becoming
increasingly
clear that our
understanding of
human nature,
psychopathology,
and change
processes will
be increased by
a metatheorical
scaffolding that
honors the
validity of
different
epistemologies,
recognizes the
limits of each,
and provides a
systematic way
to organize them
such that the
different
approaches
synergistically
complement,
rather
contradict, one
another? I
believe that
Wilber’s
integral theory
is capable of
lending a bit
more room for,
and order
amongst, the
many differences
we find in the
field of
psychotherapy.
Simply consider
the differences
between radical
behaviorism and
classical
psychoanalysis.
Their
conclusions were
virtually
opposite, but
what else would
you expect when
Skinner posited
that the only
data worth
studying are
externally
observable
behaviors and
environmental
contingencies
and Freud was
primarily
concerned not
only with
internal
experience, but
largely
unconscious
determinants of
experience.
Skinner
privileged
looking from the
outside; Freud
privileged
“looking” from
within. It’s not
that one of them
was right and
the other wrong.
They were both
partially
correct and both
partially
limited because
they didn’t look
at the subject
matter from more
than one
perspective.
An article I
wrote with
Wilber for the
issue of Journal
of Psychotherapy
Integration
devoted to
unification
briefly touches
upon some of
these issues,
though we were
asked to keep
the article to
5-10 pages,
which was quite
a challenge. I
am beginning to
work on a much
longer, more
detailed article
on Integral
Psychotherapy
and its
meta-theoretical
approach to
psychotherapy
integration that
I will submit to
JPI.
Paul
Wachtel, 22
February 2006
Dear
Andre,
Welcome
to the dialogue
and thank you
for your
stimulating
contribution.
One question
about which I am
unclear – what
makes the first
set of examples
of system from
interior
"interior" and
systemic from
exterior
"exterior"? If
anything, I
would at least
initially think
of watching the
video tape as
"exterior" and
interpretive,
intersubjective
thinking as more
"interior. Was
there a typo, or
am I missing
something basic?
I
am clearer about
exploring
cultural
patterns of
meaning making
as in a sense
"interior" and
investigating
the effects of
social-political-environmental-economic
regulation of
society as
"exterior."
But
finally, as one
more difference
among us that
probably also
needs to be
taken into
account (and, of
course,
eventually
integrated, or
at least the attempt
made to bridge
the
dichotomies), I
am aware that,
although I feel
largely in
agreement with
much of what you
are saying, and
find some of it
extremely
perceptive, I am
also, by
inclination,
somewhat
suspicious (this
is not quite the
right word–
sounds too
hostile; maybe
"disinclined
toward" or
something like
that) of schemes
that are too
abstract. Your
illustrations
help to
concretize. But
there is
something in the
overall scheme
that feels like
it looks too
much at the
world from outer
space, denoting
that, as we
mortals clash
and bump into
each other, we
are missing that
there is north,
south, east, and
west (even
though, to be
strict about it,
those axes are
more earth-bound
than universal
in a literal
sense). I am
deeply committed
to theorizing,
but I guess a
bit more
skeptical about
"meta"
theorizing. It
has the danger
to me of being a
little too up in
the air.
But
again, that is a
matter of taste
and style, not a
critique. I
mention it to
alert us to
still another
way in which we
can sail by each
other, blithely
unaware of other
possibilities
because they are
not coded to
appear on our
radar screens.
Andre
Marquis, 22
February 2006
Dear
Paul,
Thanks for your
prompt reply.
You are correct
that I made a
typo regarding
systems from the
interior and
exterior (I
accidentally
reversed them; I
apologize for
that and
appreciate your
attending to
details). It
should have
looked as you
suspected:
System
from
Exterior:
(Interobjectivity):
Systemic
analyses
(including
videotaped
sessions) ala
Greenberg's
(1999) intensive
observation,
measurement,
and analyses of
concrete-change
performances; as
well
how client and
therapist
engagement
evolves
(social-autopoetically);
any other
external
analyses of
systems
such as of
environmental
consequences
that impact
client outcomes
System
from Interior:
(Intersubjectivity):
Interpretive
inquiry in
general
(Riouer,
Gadamer, Giorgi)
including
hermeneutic
investigations
of the
intersubjectivity/in-betweeness/fit
of client and
therapist
(Stolorow et al)
I also
appreciate your
wariness of
overly abstract
schemes.
Although it may
not have been
clear in my
previous reply,
I am committed
to theorizing
only to the
extent that it
translates into
more effective
practice. Of
course, there is
the matter of
how to evaluate
if any theory
actually
improves
clinical
practice, and
that is part of
the dialogue
that has been
taking place
throughout the
last week on
this listserv.
That will also
be part of my
career-long
research agenda.
There is also
the issue of the
different ways
that theories
can facilitate
more effective
practice (for
instance, by
changing the
therapist, in
contrast to
changing the
specific
interventions
used).
As I mentioned,
many, many of
the details of
an integral
approach to
psychotherapy
integration (PI)
remain to be
worked out. And
there won’t be
just one working
out of it.
Whether from
journal
publications
that receive
critical
responses,
dialogues on
this listserv,
my own clinical
experiences, or
more controlled
experimental
research,
disconfirming
details will
hasten my
accommodating
integral theory
to “fit with the
facts” or
“down-to-earth”
practicalities
of clinical
practice. Thus,
much of my
challenge will
involve a
delicate balance
of what integral
theory’s AQAL
model can
assimilate and
how the AQAL
model will need
to accommodate
itself to “fit
the facts.”
As I have begun
to formulate my
ideas on an
integral
approach to PI,
I have become
aware that a
large part of
how integral
theory can
influence the
practice of
psychotherapy is
by changing how
one
conceptualizes
the human
condition, the
multitude of
factors
influencing
psychopathology
and suffering,
and
comprehensive
treatment. Of
course, I see
other valuable
aspects of the
integral model
being
significantly
helpful; for
example, its
encouraging/urging
clinicians to
deeply train
their attention,
awareness,
presence, and
compassion so
that their
capacity to be
with and bear
witness to
clients’
suffering is
enhanced. Which
is not to say
humanistic
encounters are
all that is
needed; I am a
firm believer
that compassion
and care must be
complemented
with technical
expertise and
honed clinical
judgement.
Tullio
Carere, 23
February 2006
Hi
Paul,
I look forward
to discussing
the following
points over a
cappuccino, or a
glass of
Chianti:
1. You think
that "the
controls of
systematic
empirical
research are very
substantially
better than the
'discipline' the
lone clinician
can muster."
Better for what?
If I had to
choose between a
therapist with a
disciplined mind
and one who is
perfectly
knowledgeable
about all
systematic
empirical
research on
earth, I would
have no doubt
and choose the
former –
wouldn't you do
the same?
Besides, a man
of discipline
looks for the
company of other
men of
discipline, just
as a man of
empirical
research prefers
the company of
other empirical
researchers.
Discipline of
mind is not a
matter of lone
clinicians, it
is an
intersubjective
enterprise like
empirical
research.
2. You think
that I am
"too
cavalier and
dismissive
toward empirical
data". In my
self-perception
I am only
dismissive
toward the claim
of hegemony
of empirical
data over our
field. I believe
that it is
dangerously
reductive to
think of
psychotherapy as
a primarily
scientific
enterprise
(which leads to
the dangerous
idea that the
medical model --
empirically
supported
manualized
procedures to
treat specific
disorders or
meet specific
needs -- is a
superior form of
treatment). In
my view
psychotherapy is
a primarily
ethical
discipline,
inasmuch as both
patient and
therapist are
engaged in a
relationship in
which they
decide at any
single step what
to do in a
relationship
involving
meanings and
values. In an
ethical
perspective
(pre-conventional
–conventional
–post
conventional),
empirical
science and even
randomized
clinical trials
have their own
place. A manual
is better than
arbitrariness,
as the capacity
and the
responsibility
to choose the
right thing to
do in the unique
circumstances of
a
psychotherapeutic
encounter is
better than any
manual.
3. In an ethical
perspective --
in which
manualized and
truncated
treatments can
be the right
choice for
inexperienced
therapists and
low-budget
public services,
as well as for
the conventional
side of all of
us -- the aim is
to progress from
a conventional
(school based,
theory and
protocol driven)
to a
post-conventional,
genuine therapy,
in which the
interaction
between patient
and therapist is
less and less
ruled by
theories and
protocols, and
more and more
guided by
dialogue and
moment by moment
assessment of
whatever the
process requires
of both members
of the
therapeutic
couple.
Technical
procedures have
their place here
too, but in a
heuristic, not a
stereotyped mode
("the experience
of the community
to which I
belong and my
own tell me that
a given
procedure could
be useful in
similar cases:
let us see what
happens if I try
it here, how it
will be
experienced be
my patient and
myself in this
specific
circumstance").
4. In genuine,
predominantly
post-conventional,
dialogical
therapy a
scientific
approach is
essential, but
not in the form
of the
application to
the interaction
here and now of
some guidelines
that some
empirical
researchers have
concocted there
and then. The
dialogic
therapist is
primarily a local
scientist
(in dialectical
tension with the
local artist
- the dialogic
therapist being
in fact a dialogic-dialectical
therapist).
It means that
the therapeutic
relationship
becomes the
laboratory where
all sort of
hypotheses
relevant to the
present case are
formulated,
discussed, and
tested in a
variety of ways
by a couple of
local scientists
(the patient is
co-opted as an
assistant).
Besides, the two
scientists
produce
documents
(particularly in
the form of
recordings of
the session or
post-session
questionnaires)
for monitoring
the process and
correlating
process and
outcome. At the
level of
dialogical,
post-conventional
therapy the aim
of empirical
research is not
to demonstrate
the efficacy of
some manualized
procedures for
specific
disorders (the
aim of empirical
research at the
conventional
level), but to
correlate
process and
outcome. The
process develops
in its own,
unforeseeable
way, what we
need to know is
to which extent
the outcome has
been affected by
the process. As
in the study of
all historical
process,
research is documental,
not experimental.
And the
scientific
historian interprets
the documents,
does not make
statistics with
them.
Tullio
Carere, 24
February 2006
I
wrote: "If I had
to choose
between a
therapist with a
disciplined
mind..". Sorry:
I did not mean
"a therapist who
has fully
disciplined his
or her mind",
nor "one who has
approximated
that goal to any
significant
degree", but
just "a man of
discipline",
i.e. a man who
has prioritized
the discipline
of the mind (in
the form of
epoché,
of the
noetic/dianoetic
dialectic, or
else) over the
learning of any
empirically
supported
procedure.
Paolo
Migone, 24
February 2006
Dear
Tullio,
I have the
feeling that to
rely on ethics
is quite
useless,
especially today
when we are in a
multi-cultural,
multi-ethnic and
pluri-religious
age. Everybody
knows that a
given cultural
population may
have ethical
principles that
are considered
unethical by
others. And
everybody knows,
as well, that
often the
therapists who
do big technical
"errors" o
behave
unethically
(according to
other
therapists) say
that they did
the right thing
and/or
"rationalize"
their behaviour.
I think we need
to find other
ways to deal
with the
problems you are
discussing
about.
Tullio
Carere, 26
February 2006
David
Allen wrote:
<<Don't
we all agree
that we need
both empirical
research to
reduce the
biases of
clinical
observations
AND clinical
observations
to reduce the
inherent
limitations of
our ability to
measure
psychological
constructs in
empirical
research?
Not only
scientists but
patients
responding to
psychological
measurement
can deceive
themselves as
well as
others. The
two methods of
discovery
compliment one
another to my
mind; another
example of
"both-and"
thinking
rather than
"either-or"
thinking.
In the
same
dialectical
vein, of
course every
"theory of
everything"
generates a
competing
theory of
everything.
The two
of them are
then
reconciled,
generating yet
another
thesis-antithesis-synthesis.
This is
how knowledge
grows as we
get closer and
closer to
truth. I
think this is
an argument in
favor of the
genesis of
metatheories,
not against
it.>>
David,
You point to a
contradiction of
mine. I have
been praising a
dialectical
approach, but
then I seem to
be non
dialectical when
I suggest that
we could or
should move from
the ground of
endlessly
conflicting
theories to the
non theoretical
ground of
common/uncommon
sense. Let me
try to explain.
I wrote in a
previous
posting:
<<In my
view nothing
is wrong with
dichotomies,
mostly. To the
contrary,
dichotomies
are there to
correct
therapists'
and theorists'
one-sidedness.
Behavior
therapy was
born to expose
psychoanalysis'
one-sidedness.
Insight vs.
action
therapies is a
useful
dichotomy,
because it
exposes the
one-sidedness
of both. It is
good, but not
good enough.
The really
good thing is
when someone
transforms the
dichotomy into
a polarity.
That is, when
someone
understands
that insight
and action are
not two
definitively
and
insuperably
different
things, but
the two terms
of a "cyclical
dynamics", as
Paul called it
in his
pioneering
work. This is
how dialectics
works: the
apparent
separateness
and
one-sidedness
of the two
terms of a
contradiction
is transcended
(aufgehoben)
when the
relation
connecting the
two is seen
and
implemented>>.
How
is a synthesis
or integration
between
psychoanalysis
and behavior
therapy ever
possible? Is it
a case of
"theoretical
integration"? No
way. How could
such
incompatible and
incommensurable
theories be
"integrated"? It
is impossible. A
synthesis is
possible,
but not on a
theoretical
ground.
You have to look
at what happens
in practice.
A patient came
to me a month
ago, asking for
an
antidepressant
medicine for his
obsessive
disorder (he had
read of this
indication). I
replied that I
am a
psychiatrist,
but prescribe
medicines only
in the context
of a
psychotherapeutic
relationship. He
accepted four
sessions, to
begin with. I
gave him a low
dose of
citalopram. At
the third weekly
session he came
and said that
the obsessive
disorder had
greatly
improved, but
now he had a
painful feeling
of loneliness
and of being
abandoned. He
saw that the
obsessive
disorder was a
defense against
the underlying
painful feeling,
which had
surfaced thanks
to the medicine.
He was now
willing to work
through his
feelings, and
accepted a
three-month
contract of
psychotherapy.
What has
happened? Have I
integrated
psychopharmacology
and
psychoanalysis?
Yes, I have, and
successfully.
Have I
integrated
psychopharmacological
and
psychoanalytical
theories? Not at
all. The
dialectic of
acting (not only
behaviorally,
even
pharmacologically)
and
understanding
does not happen
on a
theoretical, but
on a practical
ground. The
ground of common
sense, in fact.
The common
ground of the
basics of
experience,
where you find
common needs,
factors, goals,
as Hilde put it.
Theories usually
just clash, very
seldom produce
dialectical
conflicts
conducive to
some sort of
synthesis.
Theoretical
clash is useful,
as I said and
repeat. But in
order to
reconcile
conflicts you
usually have to
move to a
different
ground.
Hilde
Rapp, 26
February 2006
Dear
Andre,
Thank
you very much for
your contribution.
I have just come
back from working
abroad and I
apologize
that I don’t have
time right now to
respond in the way
you deserve.
I
just want to say
that I too am
broadly
sympathetic to Ken
Wilber’s work, and
indeed I have
been in
touch with Mike
Mahoney over
some years. I am
also in
touch with Don
Beck and
Chris Cowan
who are
spearheading the
successor to the
Gravesian project
in social
psychology,
Spiral
Dynamics ( SD). As
you know, this
model is
extending
Maslow’s
hierarchy of needs
and specifies
needs in
terms of
values on
the one hand and
life conditions on
the other. A few
years ago, Don has
linked up with Ken
Wilber to
formulate SDI, the
All Quadrant All
Levels integration
( AQAL) you
have referred us
to . I became
interested in
these approaches
precisely because
they
offer
meta models
rather than
models, and they
do so in very
useful ways
that ‘chime’ with
what I have been
grappling with
since my Frankfurt
School days in the
sixties and they
also provide a
helpful way of
mapping
the
bio-psycho-social
model as it
is current in
medical
anthropology and
in the health
sciences in
general in the UK.
Any
four quadrant
approach,
including my own,
is ,
wittingly, or
unwittingly rooted
in the ancient
fourfold mandalas
and coordinate
systems
which we
find in all
cultures across
geographies and
times…
My
‘quarrel’ is only
ever about the
degree to which a
broad approach
becomes a
‘school’ and
looses some its
openness because
language becomes
standardised to a
certain
extent and
the model attracts
a ‘following’,
even though it was
originally
designed to
be a shared ground
map for
leadership
project.
This is
often an
un-intented
consequence of its
usefulness and
success: not
wished for –
usually- by the
person who has
offered
this
particular way of
thinking to start
with.
I
am merely
passionately
advocating for
staying open to
the future,
remaining
respectful
of complexity and
being
staunchly modest
in the face of
what is
unknown and
perhaps
unknowable. I am
wary of being too
systematic-
precisely because
certainty it is
alluring and
tempts us to wish
for the
possibility of a
comprehensive
model, theory or
approach – I am
in the words
of the poet John
Keats, adviocating
for
‘negative
capability’
willing to bear
the anxiety of
doubts and
uncertainty,
paradox and
complexity…
Hence
my insistence on
integrat-ive-
rather than integ-ral,
ad-verb
rather than ad-jective…
construct- ivist
rather than
construct- ionist…
as they say, in
the beginning was
the verb,
not the
noun!
In
other words,
Marx was not
a Marxist and
Freud was not a
Freudian- but both
were cutting edge
thinkers who
changed their mind
and outlook
frequently as new
discoveries were
made and new ways
of thinking about
then became either
necessary or
attractive – and
this is also true
of Ken, Don and
Mike…, but not
always true of how
their work is used
in the
field…
That
having being said,
I too am
happy to be an
ally, and I am
genuine
appreciative of
the ‘integral’
project
insofar as I
have become
familiar with it…
I
hope I will find
time to respond to
your points in a
more detailed and
specific way…
Allan
Zuckoff, 26
February 2006
Tullio
wrote:
<<How
is a synthesis
or integration
between
psychoanalysis
and behavior
therapy ever
possible? Is
it a case of
"theoretical
integration"?
No way. How
could such
incompatible
and
incommensurable
theories be
"integrated"?
It is
impossible. A
synthesis is
possible, but
not on a
theoretical
ground. You
have to look
at what
happens in
practice>>.
I believe
that in this
statement,
Tullio has
captured
precisely the
problem with the
kind of
"meta-theory"
described by
Andre. Because
of the
differences in
their
foundational
assumptions
(what they take
to be
axiomatic),
there is no
common ground on
which the theory
of
psychoanalysis
and the theory
of behaviorism
can meet—much
less the theory
of behaviorism
(which asserts
that human
behavior is
strictly
determined by
external
contingencies)
and the theory
of humanistic
and existential
psychotherapy
(which asserts
not only that
human beings
are purposeful—of
course there
have been many
efforts, however
flawed, to
reconcile
purposefulness
and
behaviorism—but
that we are
capable of
freely choosing
our actions, in
ways that are
not subject to
causal
determinism and
thus that render
behavior in
principle
inevitably
unpredictable).
As
Tullio argues,
what calls for
integration in
psychotherapy are
the various
strategies and
techniques of
intervention/healing—a
pragmatic
integration. The
theories, in
contrast, because
they are not only
incomplete but
also false, call
not for
integration but
replacement via
rethinking and
reconceptualization.
The theory of
evolution does not
represent any kind
of “integration”
of the previously
existing theory of
divine
creation.
Yet,
this still does
not mean that
"common sense" is
an adequate ground
for practice. For
thousands of
years, human
healers stumbled
upon various
remedies that
actually did
heal—yet the
theories
(explanations) of
why they
healed were
completely wrong,
and thus healing
remained very much
a hit-or-miss
proposition. It's
taken until the
modern era
for theories
(e.g., the microbe
theory of
contagious
illness) to be
developed that
capture the truth
well enough to
lead to reliable
intervention.
Unfortunately,
when it comes to
theories of
psychotherapy, I
suspect we are
still in the
equivalent of the
pre-modern era.
For example, the
theories of
behaviorism and
psychoanalysis,
different as they
are, both rest on
a foundation of
Cartesian
mind/body dualism.
Without going on
insufferably,
suffice it to say
that my
intellectual wager
is that this
dualism is
(bluntly put)
wrong, and thus
that any theory
upon which it is
founded must be
overcome—discarded
or, at best (in
Tullio’s
framework),
sublated.
Praxes
are integrated;
theories are found
wanting,
discarded, and
replaced. It seems
to me that both of
these tasks are
vital to the
continued
development of
psychotherapeutic
healing.
George
Sticker, 26
February 2006
My
preference is for
an assimilative
approach to
integration, in
which a preferred
theory is
maintained and
techniques from
other approaches
are assimilated.
However, the
challenge after
successful
assimilation is
accommodation -
changing the home
theory so that it
can accommodate a
technique that
originally would
not have been
suggested by it.
Is accommodation
possible or must
the theory be
discarded in favor
of a synthesis? I
don't know, and
that is the
challenge we face.
Hilde
Rapp, 27
February 2006
Alan
wrote :
<<As
Tullio argues,
what calls for
integration in
psychotherapy
are the various
strategies and
techniques of
intervention/healing—a
pragmatic
integration>>.
I
agree. For me the
question here
becomes: what
outcome do we seek
to achieve?
For the sake
of argument, the
psychoanalyst
might say
that the aim of
the therapy- the
outcome it drives
towards, is that
the client should
complete the
developmental task
of
emotionally
separating from
his/her mother in
order to become a
viable adult. The
cognitive
behaviour
therapist might
reformulate this
as the
client needs to
learn certain
cognitive
behavioural skills
which involve the
false belief that
they cannot
function without
their mother, the
emotional
skill of managing
their own
emotions, social
skill of learning
to ring up friends
when miserable,
practice managing
their anxieties
when decision
making etc etc…The
analyst might
agree that this is
the way forward,
but might choose
to express the
means in
theoretically
driven different
language… and this
story could be
told with respect
to most
approaches current
in psychotherapy…
Past
Sepi conferences
have demonstrated
how good our
colleagues are in
this sort of
exercise in
translation,
transposition and
reformulation.
Alan
went on to say:
<<The
theories, in
contrast,
because they are
not only
incomplete but
also false, call
not for
integration but
replacement via
rethinking and
reconceptualization.
The theory
of evolution
does not
represent any
kind of
“integration” of
the previously
existing theory
of divine
creation>>
If
we go back to the
original meaning
of “theory”
( theorein) in
Greek, it means “a
way of seeing” ,
rather than a an
body of laws
or
relationships
which organize a
set of systematic
observations.
It seems to
me that most of
our
psychotherapeutic
” theories”
function
more like values
which
organize our
preferred ways of
seeing- or
understanding
the observations,
presumed facts,
and our
relationship to
what we know and
do in the
complex
world around us.
The African
philosopher John
Mbiti once
observed that
theories are
stories that help
us to cope with
our fear of the
unknown…
I
therefore agree
that we are
working in a
proto-
theoretical space,
and I submit that
the value of
the kind of
meta-theoretical
framework
I am proposing is
that it can act as
a shared ground
map which allows
us to organize
such ‘stories’
in terms of the
underlying values
and facts
that
particular
individuals and
professional ‘schools’
see as
particularly
helpful for
our practice.
Working
integrat- ively
then becomes not
the endeavour to
seek a synthesis
or resolution of
differences, but
rather, an
effort after
seeking an
understanding
of how different
positions are
articulated, what
conflicts arise
between them and
when, where , why
and in what
context this
matters.
As
Andre
pointed out, this
is also the
arena where
Spiral Dynamics
and Integral
Theory are
making a
contribution, not
necessarily
specifically
to psychotherapy,
but to our general
understanding of
the dynamic
evolution and
articulation of
value systems with
proto-theoretical
content and how to
work with
conflicts between
them.
After
such a ‘diagnosis’
of the
actors and
positions in a
given
conflict,
such a
meta-framework
also allows us to
collect and
organize
best
practice examples
of how to transform
these
conflicts in a
particular
practical
situation where
colleagues are at
loggerheads about
the ‘treatment’ of
a particular
client or patient.
The
journal of
Psychotherapy
Integration
is full of
such best
praxis examples-
and George has
contributed many –
and indeed our
SEPI conferences
are always an
exercise in
conflict
transformation in
action. Of course
there are
entrenched
conflicts for
which we have not
found a
process, or
perhaps we haven’t
tried yet…
Allan
Zuckoff, 27 February
2006
George
wrote:
<<My
preference is
for an
assimilative
approach to
integration, in
which a
preferred theory
is maintained
and techniques
from other
approaches are
assimilated.
However, the
challenge after
successful
assimilation is
accommodation -
changing the
home theory so
that it can
accommodate a
technique that
originally would
not have been
suggested by it.
Is accommodation
possible or must
the theory be
discarded in
favor of a
synthesis? I
don't know, and
that is the
challenge we
face>>.
I
think this model,
drawn as it is
from Piaget’s
model of
individual
learning, provides
an appealing
account of the
process of the
(ideal) individual
practitioner. For
anyone who is
plying his/her
trade as a
psychotherapist,
challenges will
arise that cannot
be neatly fit into
one’s existing
sense-making
structure; whereas
the rigid
therapist rejects
the apparent
anomaly and
insists upon
forcing the new
challenge into
his/her
procrustean
theoretical bed,
the open therapist
acknowledges the
poorness of fit
and adapts to the
novel
circumstance.
But,
how much do
practitioners’
“theories” change,
as opposed to
their praxes? If I
am a
client-centered
therapist and I
notice that
whatever client
speech I empathize
with occurs more
frequently, how
likely is it that
I will conclude
that my empathy is
merely (and
mechanically)
reinforcing the
client for certain
verbal behaviors?
I think it’s more
likely that I will
conclude that I am
empathizing
accurately,
inviting the
client to explore
more thoroughly
that area of
his/her
experience, and
perhaps
incorporate the
idea that I can
guide my sessions
towards deeper
exploration by
empathizing more
actively. Because
client-centered
and behaviorist
theories offer not
just different,
but mutually
exclusive accounts
of why people act
the way they
do—and once I buy
into the theory of
reinforcement, I’m
forced to admit
that I’m not
eliminating
conditions of
worth but merely
changing them into
more benign
versions.
Thus
I’m not sure the
assimilative model
does the job from
the standpoint of
the theoretical
development of the
discipline. This
is essentially a
model of “normal
science” in Kuhn’s
sense: when a
widely-accepted
theory provides
the foundation for
a great deal of
new knowledge
discovery, it is
maintained via
small
accommodations.
But if our field
is still
pre-paradigmatic—driven
by incompossible
theories—then I
think what is
needed may be more
“philosophizing
with a hammer.”
Allan
Zuckoff, 27 February 2006
Dear
Hilde,
I
find much of what
you propose
helpful to my own
thinking about
these matters.
The
statement that
<<most of
our
psychotherapeutic
” theories”
function
more like values
which
organize our
preferred ways
of seeing- or
understanding
the
observations,
presumed facts,
and our
relationship to
what we know and
do in the
complex
world around
us>> captures
something
important for me,
going directly to
my sense of a
disconnect between
what we normally
mean by the term
“theory” and the
way that
“theories” seem to
function in the
work of
practitioners.
Yet
I also wonder
whether the
theories
themselves—psychoanalysis
versus
behaviorism,
say—are so readily
integrated as your
example suggests.
The behaviorist
may admit that the
source of a
dysfunction lies
in the early
history of an
individual—presumably
the occasion of
the “false belief
that they cannot
function without
their mother”—but
will also insist
that the belief
was established
via reinforcement
patterns that have
presumably
continued to
obtain. The
psychoanalytic
claim that, say,
the “belief” is
grounded in
fixation of
cathexes will
presumably be
given short
shrift. So I
believe that what
you have
successfully
re-languaged
remains at the
level of praxis,
rather than of
theory.
I
also remain
uncertain about
the value of
“meta-theory” in
the sense you are
describing. In the
beginning of The
Order of Things,
Foucault
quotes a story by
Borges, in which a
certain ancient
taxonomy goes
something like
this (I paraphrase
broadly, and with
apologies): a)
Solid things b)
heavy things c)
things that belong
to the emperor d)
things that from a
distance look like
a chicken…
Foucault’s
point, of course,
was that the
conceptual space
within which such
a taxonomy could
be comprehended no
longer exists, and
is so foreign to
our own as to
render those
letter labels [a),
b), c)] absurd to
us. However,
unlike Foucault, I
would want to
argue that this
taxonomy is not
merely the product
of a different
“episteme,”
but an inferior
one. Because
if knowledge does
not progress, but
merely changes,
then we are all
absurd.
My
concern about the
“metatheoretical
space” defined by
Andre is that it
is uncomfortably
like Borges’
taxonomy, and I’m
not sure what is
gained by placing
conflicting
constructs in a
defined order, or
within a single
plane. While I see
the value in
trying to draw out
commonalities
among competing
theories, once
again at the level
of praxis, I don’t
think we will
achieve maturity
as a discipline
until we are
precisely able to
achieve, at the
level of theory,
“a synthesis or
resolution of
differences.”
David
Allen, 27 February 2006
I
completely
disagree that
there is no common
grounds on which
the theories of
psychoanalysis,
psychopharmacology,
behavior therapy,
cognitive therapy,
humanistic therapy
and family systems
theories can
meet. In my
opinion, it only
appears that way
if one views
these theories as
monolithic wholes
that must be
accepted or
rejected in their
entirety, and
conceptualize the
various theories
based on the
arguments of each
theory's most
extreme,
reductionistic
adherents. Each
theory is in
fact a collections
of ideas with
common threads
that are then
applied to various
observed phenomena
in an attempt to
understand
them. Some
of the conclusions
based on theory
may be right while
others completely
wrong.
No
behaviorist I know
thinks that human
behavior is ONLY
determined by
external
contingencies.
They just choose
to intervene
there.
Social learning
theorists even
look at the
interpersonal
environment,
although they do
so in an un
system-atic way
(if you'll pardon
the pun).
Likewise, you
don't have to
believe that OCD
is caused by harsh
toilet training
(an empirically
disproved idea
from analytic
theory) to believe
in the general
validity of the
concept of defense
mechanisms (even
if you call them
mental schemas or
automatic
thoughts).
Tullio,
you could in fact
approach what
happened with your
obsessive patient
using a
theoretical
integration of
pharmacology and
psychotherapy,
such as a
stress-diathesis
model.
Hilde
Rapp, 27 February
2006
Dear
Allan,
Thank
you. I agree with
most of what you
say, which
suggests to me
that I have – as
I do from
time to time- left
out parts of the
argument because
they are too
familiar to me by
now.
Yes,
I agree that
the potential
accommodation
between the
caricatured
analyst and
behaviour
therapist
positions is
entirely pragmatic-
they would agree
on what
needed to be
done,
but they would go
about it by
different methods/techniques
and they
would justify
what they do
differently-
ie take
recourse to
different as
well as- usually-
incompatible
theories. The
proposed
common ground is
purely functional.
In
a previous mail to
Andre I voiced
similar concerns
to those advanced
by you, although
less eloquently
and explicitly.
Tongue in cheek:
fuzzy
semantics are
useful to a
degree, but beyond
that they become woolly
! Even in a
scenario where
we could
ever work in
an “integral”
manner, sufficiency
would
increasingly
work against transparency
and one would
need an
international
mainframe
collaboration to
work out a
therapeutic
algorithm!
In any case,
temperamentally,
I
would probably
always have
an aversion
to any approach
that is
potentially
totalizing- Bob
Niemeyer made a
very good case
about this some
years ago,
reminding us of an
attempt by
Goebbels’ cousin
to create an
integrat-ed
psychotherapy in
Nazi
Germany…
So,
my
integrative
framework should
perhaps be simply
called a
meta-framework
rather than a
meta-theoretical
framework? It
transcends
theories in so far
as it does not
aim to
integrate them but
merely to organize
them. Its
purpose is to give
us a shared ground
map which allows
us to map or
locate theories
with respect to
their
central
focus: does the
theory focus
most
strongly on
subjective
experience ( Q1) ,
does it focus on
culturally
situated
inter-subjective
dialogue ( Q2) ,
does it aim
to organize
on
neuroscientific
and
cognitive-emotional-
developmental
research findings
into new
understandings of
the human
mind/psyche? ( Q3)
, or does it focus
on the
socio-economic,
environmental and
political
determinants of
mental ill
health (
Q4) or, to
be more
specific,
does it look at
sociological
factors from
a
hermeneutic
position ( say
Foucault,
then it
would be Q2
&Q4) or more
from a positivist
position (
empirically
grounded, drawing
more on
quantitative
studies, say
evolutionary
theory) then it
would be located
across
Q3&Q4…
The
purpose of such a
mapping would be
to explore
along which
axes of enquiry
the major
conflicts lie
with a view
to learning
something from
each other without
giving up our
positions if the
approaches look
like they are too
incompatible. This
would be to
advance academic
enquiry and
practical skill
and knowledge
building and
CP/E/D.
Or
more practically
still, we
might want/ need
to transform a
conflict between
colleagues with
shared
responsibility for
a shared patient
or client- Tyler’s
issue, for example
– this would be
leadership and
conflict
transformation
work.
What
we tend to learn
by using a meta
framework
approach and
we can
tolerate, nay,
embrace difference
and healthy
competition, is
usually a new
technique which
borrow and
assimilatively
integrate into our
own
approach.
What
we are invited to
let go off is our
fear of
difference, our
competitive desire
to win, and our
discomfort in the
face of not
knowing and
our
anxieties about
not being in
control…
Tullio
Carere, 28
February 2006
Paolo
Migone wrote:
<<
Dear Tullio, I
have the feeling
that to rely on
ethics is quite
useless,
especially today
when we are in a
multi-cultural,
multi-ethnic and
pluri-religious
age. Everybody
knows that a given
cultural
population may
have ethical
principles that
are considered
unethical by
others. And
everybody knows,
as well, that
often the
therapists who do
big technical
"errors" o behave
unethically
(according to
other therapists)
say that they did
the right thing
and/or
"rationalize"
their behaviour.
I think we need to
find other ways to
deal with the
problems you are
discussing about
>>.
Dear
Paolo,
Do you really
believe that we
can leave ethics
out of the door?
Ethics is
the study of how
we decide that a
choice is good
or bad, right
or wrong.
Psychotherapy is
ethics, from
start to end. In
an era
dominated by
the myth of
science many
people believe
that science is
neutral, i.e.
not grounded on
ethical and
metaphysical
choices.
Modern epistemology
has dismantled
this myth (even
Popper had to
grudgingly admit
it, in the end).
For instance,
the evidence
based
psychotherapy is
based on the
belief that you
can extract a
procedure from
the relationship
in which it is
embedded, and
administer it to
a
patient in
the same way as
you administer a
drug. You choose
to believe
that psychotherapy
works like
medicine, and
you produce
empirical data
to support
your belief. You
can produce
empirical data
to support
almost any
belief (even the
belief in
miracles: at the
Vatican they
have
a scientific
faculty for
that).
In
ethics you have
three levels. At
the ground level
(preconventional) you
are the
lawmaker: you
decide what is
right or wrong,
you
don't care
what other
people think. At
the second floor
(conventional)
you submit
to some
conventional
law: you are the
follower of some
school or
theory, you
behave according
to the
principles of
your convention
- for
instance, you
administer
protocol driven
procedures. At
the
third floor
you suspend as
much as you can
all your
presuppositions
and expectations;
you try to
understand what
every individual
situation requires,
and behave
accordingly; in
the awareness
that
your perceptions
and evaluations
are limited and
fallible, you
constantly look
for feed-back,
dialogue and
confrontation.
All three levels
are present
in different
proportions in
most of us.
Genuine
dialogue happens
at the third
floor. Faith in
dialogue
(dia-logos) is
the belief
that you can
move in life
(and in therapy)
beyond
all conventions,
guided by the
inherent logic
of any process
(the
logos) that
manifests itself
in the
relationship
between (dia)
people
willing to
let go of any
preconceptions
and expectations
to open up to
it.
Hilde
Rapp, 28
February 2006
Dear
Tullio, dear
Paulo,
In haste:
perhaps it
would help to
distinguish
between ethics
and morality on
the one hand and
religion
and spirituality
on the other.
Crudely,
by rule of
thumb: ethics
relates to
principles of
natural or
distributive justice,
while morality
relates to
conforming to
the rules and codes
of conduct
that are the norm
( conventional)
in a given
cultural
reference group.
In a similar
vein,
spirituality
relates to principles
that help us to
establish a relationship
to the
Sacred (
Divine to
some) as
such and
in
ourselves and in
our fellow
living beings (
by whatever name
or none), while
religion ties
us into sets
of beliefs and
rituals
which constitute
a particular
theology and
faith
based practice…
While morality
is grounded in
ethics and
religion is
rooted in
spirituality,
a person
can act
ethically and
yet contravene
prevailing
moral dictates (
a white person
having relations
with a black
person in
Apartheid South
Africa, which
would have been
illegal to
boot!), just as
a spiritual
person may be
burnt at the
stake for
heresy…
Having said that
I agree with you
Tullio, that psychotherapy
is a
profoundly
ethical
practice,
and- if I read
you correctly- I
agree with you
Paulo, that morality
has no place
in it-
other than as
information
about what the
client believes
or what she
might be
up
against!
Allan
Zuckoff, 28
February 2006
Dear
Hilde,
Thank
you for taking the
time to lay out
your argument more
explicitly; it
seemed very clear,
even in pre-edited
form. I do think
that we agree on
many things,
although I’m not
at all daunted by
the prospect of a
“totalizing”
theory of
psychotherapy—in
fact, I think that
should be our goal
(just as a
“unified theory”
is the goal of
physics), but I’m
certain that the
approach to such a
theory (for such
finite creatures
as ourselves) will
be asymptotic.
Your
“meta-framework”
sounds like it is
organized to lead
to the overcoming
of conflicts among
theories via
higher-order
syntheses, though
without demanding
that adherents
give up their
individual
theories until
they are ready to
do so. More than
anything, this
seems like a
skillful
therapeutic
intervention for
academics: invite
them to relax
their defenses
enough to consider
other
perspectives, but
avoid generating
resistance by not
trying to strip
those defenses
away?
Allan
Zuckoff, 28
February 2006
David,
I
certainly agree
that, in practice,
adherents of
competing
theoretical
schools borrow
from other schools
and reject aspects
of their own. But
I disagree with
your definition of
theories as “collections
of ideas with
common threads
that are then
applied to various
observed phenomena
in an attempt to
understand
them.” I
understand
theories as
well-organized
explanatory
frameworks, which
can be applied to
a range of
phenomena and
which are capable
of generating
either hypotheses
that can be tested
empirically or
truth-claims that
can be evaluated
rationally. While
certain peripheral
aspects of a given
theory (e.g.,
accounting for OCD
via anal
eroticism) can be
rejected without
having to abandon
the theory
altogether,
challenges to the
theory’s
fundamental
assumptions (e.g.,
psychosexual
development or
unconscious
process) can
render them
useless.
You
may well be right
that there are no
behaviorists left
who believe that
behavior is
determined only by
external
contingencies; I
hope that’s true.
But the very
construct of
“external
contingencies” is
not
theory-neutral;
rather, the claim
that human beings
react in lawful
ways to “stimuli”
(another
theory-specific
construct: there
is purported to be
a meaningless
physical
environment
“outside” the
person) is, for
example, rejected
by
phenomenological
and Gestalt
theories of what
is, and where
human beings fit
in what is. At
this level, both
theories cannot be
correct—and the
implications of
which is true (or,
at least, truer)
are profound with
regard to how we
view the people we
seek to
help.
Stephan
Tobin, 28 February
2006
Allan,
That
idea of an
external
reality from
which the
individual is
separate and
"stimulated
by" is a good
example of the
individualist
paradigm,
i.e., that the
self exists
prior to
interaction
with the
environment,
rather than
seeing the
person/environment
as part of a
phenomenological,
intersubjective
field.
I'm pleased
that you
mention
Gestalt
here.
Even though
Perls was a
prime example
of the
individualist
paradigm in
his behavior,
the Gestalt
theory has
always
stressed a
more
intersubjective
paradigm.
David
Allen, 28
February 2006
Psychosexual
development and
unconscious
processes are
examples of what I
was trying to talk
about -
they seem to
me to be very
different ideas
tied together with
some common
assumptions. Even
within a given
construct,
however, is it not
possible that the
various analytic
ideas about, say,
psychosexual
development are
partly correct and
partly
wrong?
The different
subschools of
psychoanalysis can't
even agree among
themselves about
all the
particulars -
Kohut had
to invent a
whole new psychic
agency (the self)
just to get his
ideas across in
order to remain
"in the
club."
I believe
even fundamental
assumptions within
a theoretical
construct can
be modified with
new evidence
without having to
throw the baby out
with the
bathwater.
I
agree
that the
construct of
"external
contingencies " is
not theory neutral
- strict
constructivists
don't even believe
that such an
external reality
exists. If
one believes that
solipsism is the
totality of the
universe, I guess
they could never
even talk about
external
conditions.
But that is the
type of radical,
reductionistic
type of stance
that is more like
religion than
science.
Perls wasn't like
that -
he wrote
extensively about
disturbances at
the interface
between
individuals and
their social
world. The
word interface
inherently refers
to two of
something.
Allan
Zuckoff, 28
February 2006
Stephan Tobin
wrote:
<<Even
though Perls
was a prime
example of the
individualist
paradigm in
his behavior,
the Gestalt
theory has
always
stressed a
more
intersubjective
paradigm>>.
David Allen
wrote:<<
Perls wasn't
like that -
he wrote
extensively about
disturbances at
the interface
between
individuals and
their social
world>>.
American though I
am, my training in
philosophy was
Continental; when
I use the term
Gestalt, I
intended to refer
not to the
“gestalt therapy”
of Perls, but to
the Gestalt
psychology of
Lewin, Kohler, und
so weiter… Thus
we all agree (I
think): there is
fundamental
disjunction
between atomistic
and holistic
models. And
perhaps that
disjunction is
consequential?
David
wrote: <<Psychosexual
development and
unconscious
processes are
examples of what
I was trying to
talk about -
they seem
to me to
be very
different ideas
tied together
with some common
assumptions. Even
within a given
construct,
however, is it
not possible
that the various
analytic ideas
about, say,
psychosexual
development are
partly correct
and partly
wrong?...
I believe
even fundamental
assumptions
within a
theoretical
construct can be
modified with
new evidence
without having
to throw the
baby out with
the
bathwater>>.
Your
point is
well-taken: it is
clearly possible
to jettison the
sub-theory of
psychosexual
developmental
stages and still
maintain the
validity of the
construct of, say,
the active
unconscious.
Although then, one
is no longer a
Freudian analyst,
but perhaps a
psychodynamic
psychotherapist.
But what happens
if one jettisons
the construct of
the active
unconscious? Can
one still claim to
hold the theory of
psychoanalysis as
valid? It’s hard
for me to imagine
what would be
left—and I suspect
at that point one
would have to say
that the theory of
psychoanalysis no
longer offers
enough explanatory
power to be worth
retaining.
David
wrote: <<[S]trict
constructivists
don't even
believe that
such an external
reality
exists. If
one believes
that solipsism
is the totality
of the universe,
I guess they
could never even
talk about
external
conditions. But
that is the type
of radical,
reductionistic
type of stance
that is more
like religion
than
science>>.
I
am not a
constructivist
myself—I find that
approach to be a
variation on
philosophical
idealism, with all
its problems (the
risk of solipsism
being one;
relativism and
ultimately
nihilism being
others). But
rejecting realism
does not require
one to veer all
the way to the
other pole.
Existential
phenomenology
(specifically,
that of
Merleau-Ponty)
starts from the
premise that
“internal” and
“external” are,
like all such
dualisms (e.g.,
“mind” and “body,”
the “immanent” and
the
“transcendent,”
the “ideal” and
the “real”)
derivative
constructs of an
inherently unitary
world of phenomena
of which human
beings are
constituents (in
the Gestalt sense
of mutually
constitutive parts
of a whole,
inseparable from
each other without
losing their
essence). This is
a remarkably hard
thought to think
(I’ve been working
on it, on and off,
for 25 years or
so), but possibly
the thought that
leads to the aufhebung
of many
destructive
dichotomies.
Science? Probably
not. Reductive or
Religious?
Definitely not
David
Allen , 28
February 2006
Sorry
about the
confusion of
"Gestalts."
What
you call "the
Gestalt sense of
mutually
constitutive parts
of a whole,
inseparable from
each other without
losing their
essence" is an
idea to which I
wholeheartedly
subscribe, so I
guess we actually
agree more than
disagree.
That idea is at
the heart of a
dialectical
variety of family
systems thinking
about which my own
metatheory
revolves.
Definitely not
reductive or
religious!
The nice thing
about it is that
one doesn't have
to give up the
ideas of
environmental
contingencies OR
unconscious
processes in order
to subscribe to
it.
If
a theorist
believes that
there are no
unconscious mental
processes, that
theorist clearly
has forgotten the
experience we all
have had of
driving down a
familiar highway
lost in thoughts
unrelated to the
drive, only to
suddenly realize
that one remembers
absolutely
nothing about
actually having
driven the
previous few
miles. One
can argue,
however, about
whether any given
thought, impulse
or emotion is
truly unconscious
in the Freudian
sense or is merely
pre-conscious
or actively
ignored.
Continue
to read the
listserv
discussion
during March, Part I
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