Editor's Note
In preparation for the 2nd Sepi- Italy
Conference, held in Florence from 24 to 26 March 2006, Tullio
Carere asked the speakers of the Conference and the members of
the Sepi listserv to participate in an on-line debate. In his
e-mail dated 22 January 2006, Carere proposed a series of
questions which have been the starting point for a rich and
passionate discussion among 16 participants (listed in the order
in which they intervened) : Tullio Carere, Paul Wachtel, John
Norcross, George Stricker, Allan Zuckoff, Hilde Rapp, Tyler
Carpenter, Ken Benau, David Allen, Andre Marquis, Paolo Migone,
Stephan Tobin, Barry Wolfe, Zoltan Gross, Luca Panseri, Mike
Basseches.
Dear colleagues and
friends,
I have asked all the
presenters at the Florence SEPI Conference (March 24-26, 2006,
http://www.vertici.com/sepi/ ) to shortly comment on a few
questions that roughly describe our topic. Here are the
questions:
Dealing with
integration means to deal with what divides the
psychotherapists. Why are
psychotherapists so much divided, in comparison to cardiologists
or endocrinologists? Maybe because psychotherapy is not a science?
Or because, as some maintain, it is not yet a
science, but it will become one when psychotherapists will decide
to submit to the rules of all good science, from physics upwards,
getting out of the medieval darkness like all other branches of
medicine? Or rather because psychotherapy is not at all a branch of medicine? Shall we
admit that there exist two quite different practices, one of
medical type, based on psychopathological diagnoses and
empirically supported therapeutic procedures, the other of
humanistic type, in which the meaning of the disorders and of the
ways to cure them does not come out of diagnostic and therapeutic
manuals, but of therapeutic dialogue and context? In that case,
shall we surrender to the irreducible diversity of the two
approaches, acknowledging that treating a patient is incomparable
with caring for a subject, or shall we understand them as the two
terms of a polarity, inside which every therapist can conveniently
locate himself or herself according to temperament and
preferences?
I hope some of you will want to join us in
the discussion on this listserv.
Paul Wachtel, 22 January 2006
In my own view, the matter is not as
dichotomous as it can seem to be in some interpretations of the
questions posed. I do not think that our divisions are
easily explained in terms of simply whether we are a science or
not. I say this in part because I think that the term
"science" itself is – or should be – a manifold term, not a
singular, prescriptive term. I say it as well because some
of the divisions, some of our difficulties in achieving consensus
are due to the subject matter of our science being extraordinarily
ambiguous and difficult to address in
very general ways rather than it being intrinsically inaccessible. (They
also derive, as I shall comment on shortly, from the very strong
connection of our particular subject matter with values and
identity).
To begin with
science: To my mind the essence of the scientific method is to
take seriously the very things that we, as psychotherapists,
particularly should understand. That it is very easy to
deceive ourselves, that our memories are suspect, that it is hard
to hold onto very much without recording it systematically, that
our very perceptions are subject both to motivated and to
unmotivated skews and distortions. The scientific method –
no, I am already slipping into a singular when it should be a
plural; scientific methods are that
quite considerable variety of ways in which we try to minimize or
reduce those effects (we can never eliminate them, only reduce them).
The problem
is that we almost have a variant of the Heisenberg principle
operating – not so much in terms of our role as observers changing
what we observe (though that, of course, is also true), but in
terms of the tradeoff that is
entailed. In quantum physics, the more we know about the
position of a particle, the less we know about its velocity and
vice versa. The very knowing of one reduces our knowing of
the other. In psychology, the tradeoff I have in mind is a
little different. It is that the more precisely we know
something, the more we can use "traditional" scientific methods,
often the less useful or comprehensive or directly applicable is
that knowledge.
This is not quite as
airtight as it is in quantum physics, which is why I said "almost" a variant of the Heisenberg
principle. Sometimes, very precise experimental studies are
about very crucially important things, and the refusal to
acknowledge that can be a rationalization for laziness or for
continuing to do what one is used to rather than responsibly
paying attention to the evidence. But all in all, the
tradeoffs are significant. The kinds of phenomena that
psychoanalytic therapists and theorists are interested in, for
example, the subtle issues of affect, conflict, motive, the
concern with the edge of experience, with what is not yet
expressible, etc – these are hard to address with traditional
experimental studies (though even here it is important to
acknowledge that some very important work has been done in this
regard).
I do
believe that sometimes we parrot the models of physics, say, or of
medicine, to the detriment of our discipline. We need to
find the kinds of disciplined observations and systematic
recording of data that are appropriate to the questions we are
asking. At our present level of knowledge, for example, one
of the technologies that is most relevant is the by now humble one
of video and audiotape recorders. This permits several extremely
important things to be added to what Freud, say, was able to see,
remember, and check on. First, and very important, it allows
others to see the same material (though there are of course
differences between seeing a tape and actually being there in the
affective field with the patient – no solution is perfect).
Second, it permits the therapist him or herself to check on what has been remembered.
It is striking how different a sequence can be when one
watches it on tape from what one has remembered (and the subtle
differences are just as important as the dramatic and obvious
ones). Third, sometimes we only see
something that has, in essence, been lying there waiting for
us to notice, after looking at it many times. In one of my
very first published papers, concerned with what is communicated
by body language, I described a pattern I did not see until I
looked at the tape an enormous number of times. But once I
finally noticed it, it "jumped out" at me and became rather
obvious.
This is
just one example of a "scientific" advance over just reporting
what one remembers from one's sessions, often at the end of the
day or even days or years later looking back on the case. I
mention the tape recorder precisely because (a) these days it is a
rather humble instrument, available to most children let alone
adults, and yet it is something that Freud simply could not
conceive would be available to psychoanalytic research; (b) it is
a method that basically retains the
usual focus of the intensive psychotherapist. That is, it
simply records the effort to be empathically attuned to the
patient's affect state, etc, rather than diverting that effort.
It still requires a good deal of inference and
interpretation to maintain certain views, but the argument has a
somewhat more solid foundation. (Some
people argue that to record a session totally changes the
configuration of what is transpiring. I believe that to be a
self-serving rationalization for not exposing either one's
clinical skills or one's ideas to this kind of scrutiny.)
More complicated or
technologically advanced ways of improving on what we can know
just from sessions are, of course, also available, often in the
form of some kind of physiological or neurological recording, but
consisting of many other methods as well. There, we quickly
find ourselves on the slippery slope of tradeoffs I referred to
above. But although we may not be able to completely resolve
that dilemma, I believe we do a better job of zeroing in on what
we need to know by shifting back and forth to some degree from one
end of the tradeoff slope to the other. That is, sometimes
shifting away from our "intuition" toward considering what a
particular experimental finding suggests, even if its ecological
validity can be in question; sometimes, shifting away from what
the "findings" are that seem to emerge from certain studies
because one is paying attention to what one's affects,
interpersonal and empathic connections, etc are telling us.
After all, Luborsky has shown that usually the researcher's
own orientation comes out ahead even in carefully conducted
studies of therapy that seem
"objective." Giving credence to what the physicist and
philosopher Polanyi called the "tacit" dimension or tacit
knowledge is an important corrective to ideologically driven scientism.
So again, in my view,
the biggest problem is falling into an either-or dichotomy.
And, in my view, there is a danger that the seemingly
ecumenical "both-and" stance can itself be an unwitting falling
into dichotomy because it implies that the two sides being equally
considered and valued are two totally
different sides.
So, to return to the
main set of questions, I do not think
" there exist two quite different practices, one of medical type,
based on psychopathological diagnoses and empirically supported
therapeutic procedures, the other of humanistic type." And I
say this even though I am a very
strong critic of the ideology that "empirical validation"
means manuals. In my work with patients, and in my
theorizing, I sometimes am going along paying attention to my
subjective experience of being with someone when a "finding"
occurs to me that alters what I am doing and how I am seeing and
experiencing what is going on between us. And in my reading
of the research literature, I am attentive to the methodology, and
(apropos what I just said) am seriously respectful of the content
of the findings, but I am also simultaneously thinking about it in
terms of what my experience in life has been of what it is to be a
human being, to be in a relationship with another person, etc.
I guess maybe that is
why I am a SEPI person. I am not a
dichotomist by and large (you could certainly find some places where I am, especially in the
realm of politics). I tend to look at both sides not just in
terms of theories (psychodynamic, cognitive-behavioral, family
systems, experiential, etc.) but also in terms of methodologies
and perspectives (empathic immersion, controlled experiments,
etc.)
Tullio Carere, 23
January 2006
Dear Paul,
thank you
for your precious response. As you begin by saying "In my own
view, the matter is not as dichotomous as it can seem to be in
some interpretations of the questions posed", I want to clarify
that in my view the scientific-humanistic dichotomy, before being
a matter which one can approve or disapprove of, is a matter of fact. I often cite B. Carey's
incipit of a noted NYT 2004 article that depicts the way the world
looks at us:
Good
therapists usually work to resolve conflicts, not inflame them.
But there is a civil war going on in psychology, and not everyone
is in the mood for healing. On one side are experts who argue that
what therapists do in their consulting rooms should be backed by
scientific studies proving its worth. On the other are those who
say that the push for this evidence threatens the very things that
make psychotherapy work in the first place.
If we acknowledge this fact in the first
place, what follows next is what we decide to do with it. We can
consider it as just the result of a simplistic attitude in our
field regarding the scientific method (or methods, as you say and
I agree), and the difficulty to understand the extraordinary
ambiguity of our subject matter. Or, beyond that, we can see in
the split of our field the reflex of a contradiction that has not
yet been dialectically articulated, and is consequently stuck in a
sterile opposition. As you fittingly observe,
<<The problem is that we almost have a
variant of the Heisenberg principle operating – not so much in
terms of our role as observers changing what we observe (though
that, of course, is also true), but in terms of the tradeoff that
is entailed. In quantum physics, the more we know about the
position of a particle, the less we know about its velocity and
vice versa. The very knowing of one reduces our knowing of
the other. In psychology, the tradeoff I have in mind is a
little different. It is that the more precisely we know
something, the more we can use "traditional" scientific methods,
often the less useful or comprehensive or directly applicable is
that knowledge>>
I am struck by you reference to the
indetermination principle, because I myself am working along the
same line. My own formulation of that principle, applied to our
field, is: The more objectively we want to
know the phenomena happening in a therapeutic relationship, the
more the subjective side of the same phenomena - emotions,
meanings, values - eludes us, and vice versa. The unawareness
of this principle is in my view the basic cause of our "great
divide". At the two sides of the divide stand respectively those
who privilege objectivity (therefore aiming at a psychotherapy
akin to medicine, in which disorders are identified through
diagnostic manuals and treated by means of empirically supported
procedures), and those who privilege subjectivity (therefore being
little interested in diagnoses and procedures, but much in the
emotions elicited and the meanings made or uncovered in the
process).
To heal the split means to me to recover a
dialectic of the subject and the object, transforming the
dichotomy in a polarity in which neither term is privileged a
priori. The implications for research are far reaching. On one
side traditional psychoanalytic research, which considers only
subjective data, on the other empirical research (especially the
one of randomized clinical trials), which is only interested in
reproducible and measurable data, have produced a situation of
impasse and reciprocal incompatibility. I believe that the impasse
can be overcome starting from two basic points.
The first is the
acknowledgment by the therapists of the necessity of documenting
their work not just with clinical notes, but also with audio- or
video recording (as you prefer) or post-session questionnaires (as
I prefer). In this way the object of study is real therapy, not a
laboratory artifact, and the data obtained are of a documental, not experimental type. The second point
regards the way of processing the data. The data of a process, be
it of historical, juridical, psychological or narrative nature, do
not lend themselves very much to mathematic-statistical
processing: what they essentially need is interpretation. Basically, to overcome
the subject/object dichotomy a research in psychotherapy should
integrate the therapist's interpretation of whatever transpires in
the session (subjective data) with the interpretation of process
documents (objective data). This is what I do in my minuscule
research group, and what in my view every single therapist could
and maybe should do, in the spirit of the Freudian Junktim: the
inseparable connection between theory, practice, and research.
Thank you
again, Paul, for your contribution to our pre-conference
discussion (I have forwarded your text to the Italian conference
discussion list), and especially for your reference to the
indetermination principle (almost).
John Norcross, 24
January 2006
To understand the psychotherapies, one must
appreciate both the robust
commonalties that unite them and the enduring differences that
separate them. To appreciate only the undifferentiated,
lowest-common denominator mass is to miss the clear distinctions
among component parts. To appreciate only the precise distinctions
of the components is to miss the larger gestalt. We should strive
to integrate the differentiated parts into the whole at a
higher level. Here, we can understand the unity and the complexity of psychotherapy.
It is to this level, I believe, that psychotherapy should
aspire.
In clinical work, we
can combine the power of the common factors and the specificity of
the differences. In fact, many of the differences among the
psychotherapies are complimentary when working with patients.
Disparate treatment content and goals of the
psychotherapies, for example, can be prescriptively matched to the
clinical needs and treatment preferences of individual patients.
Different psychotherapeutic methods have been shown to be
differentially effective for patients in different stages of
change, for another example. The insight-oriented and
motivation-enhancement methods are indicated for patients in
precontemplation and contemplation stages, while more cognitive
and behavioral methods are indicated for patients in the action
stage. And highly directive and paradoxical methods have
been shown to be more effective for high-resistance patients, for
a third example. Different strokes for different folks.
Finally, I am deeply
concerned about the tendency to bifurcate the field of
psychotherapy into bipolar camps: insight vs action
therapies, objective vs. subjective therapies, or, as implied in
the stimulus question, medical model vs. contextual model.
It serves neither our discipline nor our clients. The
alternative is not to deny real differences; the
alternative is to avoid dichotomous experiences and to appreciate
both the unity and complexity of psychotherapy, using the real
differences to enhance outcome by tailoring psychotherapy to the
individual client and the singular situation.
Tullio Carere,
25 January 2006
Thank you John for
sharing with us your deep concern "about
the tendency to bifurcate the field of psychotherapy into bipolar
camps: insight vs action therapies, objective vs. subjective
therapies, or, as implied in the stimulus question, medical model
vs. contextual model", and your belief that "it serves neither our discipline nor our
clients", coupled with the belief that "the alternative is to avoid dichotomous
experiences and to appreciate both the unity and complexity of
psychotherapy, using the real differences to enhance outcome by
tailoring psychotherapy to the individual client and the singular
situation."
I
myself am a believer in the unity and complexity of psychotherapy
(although I do not believe in the uselessness of the bipolar
perspective). Of course you are aware that we live in a world of
infidels who don't believe in the
unity of psychotherapy. For instance, in psychoanalysis the
believers in a common ground are called the "common grounders" and
are said to be one of the five or six major psychoanalytic tribes
living in a reserve, watched over with suspicion or open hostility
by all the other tribes. According to the First Law of Discussions
among Psychotherapists, whenever a psychotherapist says that
psychotherapy has the X property (e.g., it has robust
commonalities), there always is another therapist who says that
his or her thing does not have the X
property (e.g., there are at most family resemblances). Our field
produces dichotomies as other fields produce daisies. But it seems
to me that there are many more people allergic to dichotomies than
to daisies.
In my view nothing is wrong with dichotomies,
mostly. To the contrary, dichotomies are there to correct
therapists' and theorists' one-sidedness. Behavior therapy was
born to expose psychoanalysis' one-sidedness. Insight vs. action
therapies is a useful dichotomy, because it exposes the
one-sidedness of both. It is good, but not good enough. The really
good thing is when someone transforms the dichotomy into a
polarity. That is, when someone understands that insight and
action are not two definitively and insuperably different things,
but the two terms of a "cyclical dynamics", as Paul called it in
his pioneering work. This is how dialectics works: the apparent
separateness and one-sidedness of the two terms of a contradiction
is transcended (aufgehoben) when the
relation connecting the two is seen and implemented. In the same
vein, the current dichotomy between practice and research can be
transformed into a polarity if the two are no longer seen as two
separate things made by different operators with different
competences, but as the two sides of an integrated enterprise, as
I have tried to sketch in a previous posting.
I stop here,
because allergy to dichotomies is nothing, compared to the almost
anaphylactic crises unchained by dialectics in some friends and
colleagues, and I don't want to stress their immune system.
George
Stricker, 25 January 2006
I'm not sure that John and Tullio really
disagree, but whether they do or not, let me indicate where I
stand on this. I agree with John that the creation of bipolar
camps is not constructive, and often the polarities are given life
and exclude the other. However, I agree with Tullio as to the
value of a dialectic process, and that begins with opposing views
that then can be reconciled for a higher order solution (which, in
turn, gives way to further opposition and resultant syntheses, in
a continuing process). As for science and practice, my views are
in my writing on the Local Clinical Scientist, a formulation that
has the clinician acting as a scientist in a laboratory with the
patient, maintaining attitudes of skepticism and inquiry, and
learning from each encounter. This requires the systematic record
keeping that Tullio discussed earlier in order to be effective.
Allan
Zuckoff, 25 January 2006
Dear Tullio,
I’ve
enjoyed reading this exchange, and have been glad to see a
reemergence of substantive discussion on this listserv. I join the
discussion as a psychologist trained in empirical-phenomenological
research methods who has spent much of the past decade involved in
controlled trials of psychotherapy interventions, and thus as
someone who has sympathies for both sides of the dichotomy (or
poles of the dialectic, if you prefer).
In one of your
posts to Paul, you wrote:
<<I
believe that the impasse can be overcome starting from two basic
points. The first is the acknowledgment by the therapists of the
necessity of documenting their work not just with clinical notes,
but also with audio- or video recording (as you prefer) or
post-session questionnaires (as I prefer). In this way the object
of study is real therapy, not a laboratory artifact, and the data
obtained are of a documental, not
experimental type.>>
I agree that the
object of psychotherapy research should be, as you put it, “real
therapy.” I gather, though (based on past listserv posts), that
you do not consider time-limited, protocol-guided therapy provided
in the context of a research study to fit that description. If I’m
correct in this understanding (and I apologize in advance if I
have misconstrued you), then this is perplexingly dismissive of
the powerful effects such therapies have been repeatedly
demonstrated to have (as well as of the “reality” of the
therapeutic encounters I have experienced in doing such
therapies). It would also deprive us of excellent sources of the
data that I think interests both of us the most: live, meaningful
interactions between therapist and client.
Relatedly, I
am also perplexed by your suggestion of an equivalence between
recordings of therapy sessions, and post-session questionnaires.
From an empirical perspective, research on training of therapists
in motivational interviewing (the area with which I am most
familiar) has shown that the gap between what therapists think
they are doing, and what recordings show them to have been doing,
is rather substantial (especially with regard to expressed
empathy). From a psychoanalytic perspective, this should hardly be
surprising: no matter how well-analyzed, therapists have their
defenses, and their own assessment of what has happened and what
they have done in a session should reliably be expected to be
distorted in various ways. For access to the rich
intersubjectivity of therapeutic process, it seems to me that
there can be no substitute for recording of sessions.
I’ve chosen to
address two of your specific points, rather than the overarching
theoretical and conceptual issues, because I think it’s in such
points that the challenges of psychotherapy integration become
most clear. If agreement is impossible on points such as this,
then it’s hard for me to see how the rifts you have highlighted
can be healed. If synthesis can be achieved on such questions,
however, perhaps there is more hope.
Hilde Rapp, 26 January 2006
Tullio observes/ asks:
<<Dealing with integration means to deal with
what divides the psychotherapists. Why are psychotherapists so much divided, in
comparison to cardiologists or endocrinologists?>>
All knowledge, as Bion so astutely observed,
requires linking that which is similar and separating that which
is dissimilar or different – all thought and all language depends
on making distinctions. Psychotherapy has in common with the
natural sciences that part of the activities of practitioners of
psychological therapies consist in observing the client’s
behaviour, noticing regularities or patterns, and finding ways of
systematizing these observations through description, where
possible measurement, and through searching for regularities
and consistencies in the relations between observations –
something akin to formulating rules, laws and theories.
Psychiatric classification depends on such systematizing
work, including certain behaviours, signs or symptoms in the
description of clients disordered thoughts, feelings
and behaviours and excluding others in order to
arrive at a differential diagnosis.
Psychotherapy is dissimilar from
the natural sciences and similar to the Geisteswissenschaften
( sciences of the mind – what anglosaxons call Human
sciences and the arts), in that it also enquires into
subjective and cultural acts of meaning making by exploring
with clients through questioning and spontaneous self report ,
their own efforts after assigning meaning and significance to the
content of their consciousness. This activity draws on culturally
mediated symbols and metaphors as well as subtle
distinctions between affect states such as regret, remorse,
repentance, shame or guilt and culturally mediated
story grammars or forms of narrative. The negotiation of such
intersubjective meaning and perhaps even transpersonal
experience can be tapped by methods of measurement as for instance
in discourse analysis, both of key words and of non verbal signs,
such as hesitation patterns, inflection and so forth. More
usually, therapists draw on their own capacity for artistic
appreciation and, significantly, for empathic understanding
of the client’s communications, whether verbal or nonverbal,
whether in the form of reports of dreams and fantasies
or of reports of social or natural events, in ways akin to
those used by writers, poets, dramatists, film makers and
visual artists.
Tullio poses the questions:
<< Maybe
because psychotherapy is not a science? Or because, as some
maintain, it is not yet a science, but it will become one when
psychotherapists will decide to submit to the rules of all good
science, from physics upwards, getting out of the medieval
darkness like all other branches of medicine? Or rather because
psychotherapy is not at all a branch of medicine?>>
I largely agree with the points already made
eloquently by Paul and by John. Although these questions are
common, and although I very much like questions, I do not
think that we should be seduced into providing dichotomous
answers!. As you will see from my contribution to the conference
which also reflects the structure of my forthcoming
book, my understanding of integration depends on respecting
that human beings have only partial access to what may be
known about ourselves and the world. We do not have a
coherent theory of everything- and, Wilber not withstanding,
in some ways I rather hope we never will. Furthermore, we
are prisoners of language when it comes to what can be
said about what we know, and therefore we express what we know
according to different traditions of enquiry. Paradigms,
epistemologies and traditions arise in ways that are the
best fit for the purpose of examining, describing, measuring
or classifying the phenomena we wish to understand at a
given time in history. Each age brings revisions, redecisions and
innovations, some clearly advances, others cul de sacs born of fad
or fashion – whether often only time can tell which is which.
In my view the
task of integration is to establish correspondences or links
between the way we describe ( what we hope is) the
same phenomenon in one paradigm and how we describe it in another.
.
I
use four simple distinctions to map the field- each of which
connects into a particular tradition of enquiry:
I. Exploring subjective experience
II. Exploring cultural patterns of
meaning making
III. Examining and measuring bio-social
determinants
IV. Investigating the effects of the
social-political- environmental- economic regulation of
society
For instance: We may become
curious about correspondences between physiological events
such as hormone function, brain transmitter activity ( III)
and thoughts, feelings, dreams or motivational events etc ( I ).
We may want to track such patterns, insofar as we understand them
through the life span- how do they change with age and experience
(III) ? Whatever we do will be subject to interpretation (I), and
our interpretations of any findings are culturally situated (II).
Furthermore, they tend to have political implications, in
that moneys will be allocated ( or not) to research
further, and recommendations will be made via
guidelines to regulate access to treatments or
resources (IV). Integrative therapists need to negotiate the
different ways in which communities of enquiry, meaning, interest
or practice use epistemologies and language to share their
knowledge and also to mark it off from the discourses of other
disciplines with a related but different focus of enquiry. This
requires adopting a meta-perspective and , alas, a good deal
reading and thinking outside the box without loosing one’s
humility in the face of the complexity of what we are trying to
understand, and crucially to apply to responsible practice with
often vulnerable clients.
Tullio asks:
<<Shall we admit that there exist
two quite different practices, one of medical type, based on
psychopathological diagnoses and empirically supported therapeutic
procedures, the other of humanistic type, in which the meaning of
the disorders and of the ways to cure them does not come out of
diagnostic and therapeutic manuals, but of therapeutic dialogue
and context?>>
Yes there are different
traditions which are linked to different practices which serve
different social functions. Traditionally diagnostically
driven psychiatry is designed to observe, diagnose,
and then treat socially divergent behaviour. Its aim
is to restore the client or patient to a socially adapted/
adaptive state in which his or her behaviour fits within normal
parameters. It is a corrective practice and can be and has been on
occasion coercive, but it can be and often is simply normalizing,
helping the client to reintegrate into the social order and
maintaining the necessary emotional stability to function in
relation to life’s tasks.
The more humanistic type of practice tends to
aim in the opposite direction, namely to help the client to stand
back from convention and to choose freely how he or she
wants to actualize their potential which may currently be
hemmed in by unsuccessful attempts at trying to fit into a
conventional social framework. It may help people to break free
from unproductive relationships with significant others or to
liberate their creativity from humdrum and unfulfilling jobs.
In practice,
most good, and most integrative psychotherapist would see a
positive value in both these endeavours; to help someone
to have the social skills and emotional stability to play
their part as a citizen on the one hand, and to have enough
resources to make responsible and rewarding decisions on the
other: human beings need both, the capacity for forming and
maintaining meaningful relationships within the social and
cultural framework of their society and to find novel and
creative forms of self expression in the face of the challenges of
( post) modernity so that they can carry out tasks which draw on
both these capabilities.
Tullio asks:
<<In that case, shall we surrender to
the irreducible diversity of the two approaches, acknowledging
that treating a patient is incomparable with caring for a subject,
or shall we understand them as the two terms of a polarity, inside
which every therapist can conveniently locate himself or herself
according to temperament and preferences? >>
To an extent, as Paul and especially John,
have already observed, it is the client’s need which should
determine what therapeutic tasks need to be
undertaken, and the nature of the task will to a large measure
determine the method or approach used by the therapist at a
particular point in the evolution of the treatment. To an extent
most therapists will be more interested in or more skilled
at a particular way of working – more or less scientifically
or more or less artistically. If the therapist is self aware and
responsible, such preferences will be reflected in the kind
of client groups a therapist chooses to work with, which
clients he or she refers on to a colleague, more skilled in the
empirically validated treatment recommended by any national or
international guidelines or protocols insofar as these exist, are
relevant or trustworthy. Integrative therapists may be more
versatile and able to function competently over a wider range of
treatment modalities and approaches than so called ‘pure
form therapists’, but this is a matter for scientific research to
decide, where therapist orientation is matched with client outcome…
Tullio Carere, 27 January 2006
Dear Allan,
I am very
happy that you make the points below:
<<
I agree that the object of
psychotherapy research should be, as you put it, “real therapy.” I
gather, though (based on past listserv posts), that you do not
consider time-limited, protocol-guided therapy provided in the
context of a research study to fit that description. If I’m
correct in this understanding (and I apologize in advance if I
have misconstrued you), then this is perplexingly dismissive of
the powerful effects such therapies have been repeatedly
demonstrated to have (as well as of the “reality” of the
therapeutic encounters I have experienced in doing such
therapies). It would also deprive us of excellent sources of the
data that I think interests both of us the most: live, meaningful
interactions between therapist and client.>>
To begin with, for the First Law of DAP
(Discussions among Psychotherapists), your belief in "the
powerful effects such therapies have been repeatedly demonstrated
to have" can be matched against the belief of others that the
effect of time-limited, protocol-guided therapies is almost
irrelevant. Consider, for instance, the results of Luborsky et
al's 2002 mega-analysis (meta-meta-analysis). Comparing active
treatments, these authors found a non significant effect size of
.20 based on 17 meta-analyses, which further shrank to .12 when
corrected for researcher allegiance (see also Messer 2001, Messer
& Wampold 2002). Secondly, most efficacy studies are based on
a set of assumptions (namely, that psychological symptoms are
highly malleable, discrete, and relatively independent of
long-standing personality processes, that the primary focus of
treatment can be readily identified, that the elements of
efficacious treatment are dissociable and additive, that these
techniques can be implemented in a relatively brief span as
prescribed in a manual), assumptions that are not theory-neutral -
if theory-neutrality ever exists - but theory-specific of the
behaviorism of the 1960s and 1970s. Most of these assumptions are
empirically testable, and many of them have either never been
adequately tested or have been empirically falsified to one degree
or another (Westen et al. 2004). You cannot expect that a
process-oriented therapist takes such studies in great
consideration.
Real therapy
, to
me, is
what really happens in the
relationship between a patient and a therapist, not what the
therapist believes to happen as a consequence of his/her
allegiance to a theory or a protocol.
But you are well aware of the difference:
<<
Relatedly, I
am also perplexed by your suggestion of an equivalence between
recordings of therapy sessions, and post-session questionnaires.
From an empirical perspective, research on
training of therapists in motivational interviewing (the area with
which I am most familiar) has shown that the gap between what
therapists think they are doing, and what recordings show them to
have been doing, is rather substantial (especially with regard to
expressed empathy). From a psychoanalytic perspective, this should
hardly be surprising: no matter how well-analyzed, therapists have
their defenses, and their own assessment of what has happened and
what they have done in a session should reliably be expected to be
distorted in various ways. For access to the rich
intersubjectivity of therapeutic process, it seems to me that
there can be no substitute for recording of
sessions
.>>
Does audio- or video- recording permit us to
understand what really happens in a therapy? Yes and no, in my
view - more no than yes. Too often have I seen videotapes of
therapists proudly showing them in the conviction that everybody
should see what they see - namely, the efficacy of their
method - whereas what
I usually
see is different to totally different from what they see (not truer, just different).
Tapes don't record meanings, just behaviors whose meaning has to
be interpreted - and of course the meanings change according to
the theory of the interpreter. If you let go of the idea that a
tape as such shows the reality of a session, and accept that all
you have is a material that must be interpreted according to a
theory that will be extolled by some and rejected by others, your
enthusiasm for such material could rather fall off, especially if
you consider that its processing is extremely time-consuming.
In this state
of affairs, you might consider the convenience of post session
questionnaires vs. recordings. For instance, the questionnaire
that we have devised in our small research group asks the patients
to rate on a 7-point scale the session outcome and 15 items
describing typical session experiences, like "I felt understood",
or "I have seen alternatives to my usual behavior" on two columns
(respectively, "This is what happened in the session", "This is
what I expected in the session"). The questionnaire does not
yields numbers to sum to other numbers to make statistics (a game
you can play, yet of poor relevance), because the ratings are very
context-dependent (a short discussion of the questionnaire at the
beginning of the next session is mandatory - it takes very
little time and generally is very useful). It is a simple and
efficacious tool to monitor and document the process, in the
perspective of George's
Local clinical
scientist (to be dialectically balanced with the
Local clinical artist). Much more
practical and economical than any recording, as far as I know.
And, last but not least, it heals the rift between practice and
research, in the spirit of Freud's Junktim.
Tyler Carpenter, 28 January 2006
For me I suspect that I am less interested
clinically in what divides psychotherapists. People make
distinctions by nature and may argue over their respective
validity. I find I'm more interested in integrating what I
know of what is known, in the patient and what they present
for help with. In this respect I find my self drawing on a
lot about humans that present itself in the context and
conditions I am faced with. Because my patients are
currently typically seriously disturbed sex offenders, this
requires an integration of
medicine-criminology-religion-developmental
psychopathology-culture. I see no distinctions between
medicine-meaning-treatment-science, except for the purposes
of discussion with others or articulating to myself what
seems to be intuitively true and clinically effective, or
requires more investigation and thought together with the
patient and the context of treaters and security. To me to be
therapeutic is simply to say I got the mix right this time
with this person. I don't think that I'm idiosyncratic in
this approach, for by the canons of our respective
professions and the nature of who we work with, I suspect we
make the distinctions which our patients present us with for
treatment in the settings we choose to work. Or said another
way, I think any well trained clinician who undertakes to
treat psychotic and character disordered criminals in a
correctional context in which the realities of getting a
favourable result (and preventing tragic and fatal ones)
dictates that we take meaning, context, level of systems,
empirical knowledge, and medicine seriously or not work
successfully with those folks. Deviations from such an
"integration" seem to me to be more about experience. In
this light physics, chemistry, brain science, sociology,
anthropology, religion, psychology, etc. all have their
place and can be articulated in those meaningful moments and
periods when we and our patients can breathe "aha" as the elements
come together in the therapeutic ebb and
flow. When we work this way, severity becomes less
severe and more treatable. More like a difficult problem in
the process of becoming a less difficult one. If one
perseverates and is rigid in ones thinking, the question of the
extent to which this stuckness is state or trait, reflective
of damage-development-context (or most likely an admixture)
drives the moment and the therapeutic response. To split
such things into meaning-medicine-technique, except for the
purposes of teaching or discussion, is to miss a complete
understanding of the entire phenomenon at hand. It's a
little like hardening the categories, when in fact that is the
problem to be understood and developed and processed in the
moment. Why make such a moment projective
identification-cognitive distortion-perseveration, when the
solution is to standback and address the issue in one of the
numerous ways the patient, environment and tools might
address?! As to our relationship to doctors, that
division seems to be less distinct to me as the practice
seems more consumer driven and multi-disciplinary. To me
some behavior and cognitive therapy seems more like some types of
medicine, but when I reflect further or consult another
practitioner or reflect on all that is happening in my
consult with my doctor, it seems that he is drawing on a
wider understanding of therapeutics where there is much
overlap in what he and I think that the problem is.
Zuckoff Allan, 29 January 2006
Dear Tullio,
It seems to me that, if
“integration” means anything when it comes to the methodology of
psychotherapy research, it must involve finding some common ground
between “process-oriented” and ”outcomes-oriented” perspectives.
While I am far from an uncritical proponent of controlled
psychotherapy outcomes research, and I believe that questions
about what the cumulative evidence shows thus far are of
great importance, your dismissal of this entire body of research
as “almost irrelevant” does not, I think, bode well for the
project of integration.
But let us stay, as you
prefer, within the realm of process research. You write:
<<Real therapy, to me, is what really
happens in the relationship between a patient and a therapist, not
what the therapist believes to happen as a consequence of his/her
allegiance to a theory or a protocol.>>
Here we are in complete
agreement. Which makes the critical question: how can we best
research, and thus understand, “what really happens in the
relationship between a patient and a therapist”? Your claim is
that recordings of sessions are less valuable for this purpose
than I believe, due to the inevitable conflict of interpretations.
<<Tapes don't record meanings, just
behaviors whose meaning has to be interpreted - and of course the
meanings change according to the theory of the interpreter. If you
let go of the idea that a tape as such shows the reality of a
session, and accept that all you have is a material that must be
interpreted according to a theory that will be extolled by some
and rejected by others, your enthusiasm for such material could
rather fall off…>>
This, I would argue, is
not only wrong, but highly ironic and (if it were true) ultimately
destructive of any meaningful research process. The position you
articulate would leave us all trapped in the hermeneutic
circle—and thus forced in every case to insist that any one
construal of meaning is “not truer, just different” from another.
The irony comes from the fact that, by claiming that “behaviors”
have no inherent meaning, you are echoing a key (and mistaken)
element of the behaviorist position you otherwise reject. The
destructiveness derives from the fact that, like all
post-structural positions, yours fetches up in relativism and the
death of truth.
Fortunately, one need not
be a positivist to escape this trap. Merleau-Ponty showed us how:
phenomena (including behavior) are both autochthonously organized
(and thus inherently meaningful) and intrinsically ambiguous (and
thus open to multiple interpretations). Varying perspectives may
be more or less accurate—but some are truer than others, and it is
possible (and, if research is to be something other than an
endless circle, necessary) to adjudicate between them.
Thus, the problem of
recordings does not lie in either their multivocity or their
capturing of only a part of the “reality” of a session—but rather,
in finding (one or more) methods that can allow them to speak
their truth (which is, of course, not “the whole truth” but one
part thereof). The method I have used begins with the
phenomenological reduction—impossible to complete, yet vital to
undertake. I have no doubt that other methods could be viable, as
well.
I believe that the
approach I am pointing towards speaks to your own concern about
interpretations of therapeutic process being contaminated by the
theoretical (and other) biases of those who offer them as
demonstrations of their therapy’s power. At the same time, it
shares the one virtue of controlled outcomes research that I most
admire: it allows for the possibility of falsification of claims
of efficacy through public (i.e., intersubjective) evaluation,
which is as close as we can come to true objectivity in this
realm. Post-session questionnaires, while of some interest, cannot
come close either to revealing the richness of therapeutic
process, or to putting one’s claims for the power of one’s form of therapy to the
test.
Tullio Carere, 29 January 2006
Dear Allan, you write: <<It seems to me
that, if “integration” means anything when it comes to the
methodology of psychotherapy research, it must involve finding
some common ground between “process-oriented” and
”outcomes-oriented” perspectives. While I am far from an
uncritical proponent of controlled psychotherapy outcomes
research, and I believe that questions about what the cumulative
evidence shows thus far are of great importance, your dismissal of
this entire body of research as “almost irrelevant” does not, I
think, bode well for the project of integration.>> I strongly endorse a
dialectic between "process-oriented" and "procedure-oriented"
perspectives (though I don't share your enthusiasm for most
efficacy studies so far). I do not dismiss an "entire body of
research as 'almost irrelevant'", but others do. Some are
enthusiastic of that sort of research, others dismiss it (both on
the base of robust empirical data: First Law of DaP). Empirical
research is necessary, and just because it is necessary it must be
criticized (as Westen does) for the way it has been done so far,
with so many unjustified and unwarranted assumptions and biases.
Above all, I agree with Westen that empirical research should
return to real therapy as a natural laboratory in the first place,
in order to draw from the observation of real processes the
hypotheses to put to test (as opposite to the "Popperian" trend in
empirical research, which only emphasizes hypotheses testing),
with a much more balanced mix of observation and experiment. I
personally believe that empirical research in psychotherapy should
be much more of the correlational, and much less of the
experimental type.
<<…
the
critical question: how can we best research, and thus understand,
“what really happens in the relationship between a patient and a
therapist”? Your claim is that recordings of sessions are less
valuable for this purpose than I believe, due to the inevitable
conflict of interpretations… This, I would argue, is not only
wrong, but highly ironic and (if it were true) ultimately
destructive of any meaningful research process. The position you
articulate would leave us all trapped in the hermeneutic
circle—and thus forced in every case to insist that any one
construal of meaning is “not truer, just different” from another.
The irony comes from the fact that, by claiming that “behaviors”
have no inherent meaning, you are echoing a key (and mistaken)
element of the behaviorist position you otherwise reject. The
destructiveness derives from the fact that, like all
post-structural positions, yours fetches up in relativism and the
death of truth. Fortunately, one need not be a
positivist to escape this trap. Merleau-Ponty showed us how:
phenomena (including behavior) are both autochthonously organized
(and thus inherently meaningful) and intrinsically ambiguous (and thus open to
multiple interpretations). Varying perspectives may be more or less accurate—but some
are truer than others, and it is possible (and, if
research is to be something other than an endless
circle, necessary) to adjudicate between them. Thus, the problem of recordings does not
lie in either their multivocity or their capturing of only
a part of the “reality” of a session—but rather, in finding (one
or more) methods that can allow them to speak their
truth (which is, of course, not “the whole
truth” but one part thereof). The method I have used begins with
the phenomenological reduction—impossible to complete, yet vital to undertake.
I have no doubt that other methods could
be viable, as well. >>
I surely am an
adversary of scientism, i.e. the belief that science is the
ultimate key to crack open the mysteries of life and existence.
All scientific enterprise is based on some indemonstrable belief
or subjective choice (even mathematic, as Goedel saw and showed).
The death of truth is rather a consequence of the hubris that
claims that truth can be objectively known. All objective
knowledge is the result of some epistemological choices of the
subject (which the subject is usually not aware of). This
awareness, though, does not make of me a post-modernist
relativist. On one hand, this makes me try to recoup the dialectic
of the subject and the object wherever it gets lost (in positive
sciences it usually does) - which means that I always try to
uncover the hidden presuppositions, choices and beliefs behind any
"objective" knowledge. On the other, I don't believe that we are
fatally trapped inside our subjective points of view - or
hopelessly conditioned by the conditions of our lives. To the
contrary, the liberation of the subject from whatever traps or
conditions his or her existence is to me the very goal of any
psychotherapeutic effort, from the shamans on. Bion's formula
"freedom from memory and desire" epitomizes well this basic
thrust, and the phenomenological reduction is an important aspect
of this freedom - at least its first step. I am glad to read
that your method "begins" with it. You must be aware, though, that
it is not enough to begin with it. To become aware of all one's
presuppositions, judgments and expectations, and to suspend them
continuously, is a very hard discipline, and I would not say that
it is the bread and butter of most of those who devote themselves
to empirical research - who therefore quite often remain
stuck with their unsuspended and uncriticized presuppositions. But
maybe we could agree on this point: science has a good chance of
not corrupting into scientism to the extent that the scientist
practices a good enough epoché from the start to the end of his or
her work.
<<I believe that the approach I am
pointing towards speaks to your own concern about interpretations
of therapeutic process being contaminated by the theoretical (and
other) biases of those who offer them as demonstrations of their
therapy’s power. At the same time, it shares the one virtue of
controlled outcomes research that I most admire: it allows for the
possibility of falsification of claims of efficacy through public
(i.e., intersubjective) evaluation, which is as close as we can
come to true objectivity in this realm. Post-session
questionnaires, while of some interest, cannot come close either
to revealing the richness of therapeutic process, or to putting
one’s claims for the power of one’s form of therapy to the
test.>> I don't admire most
controlled outcome research for the too many unwarranted
assumptions on which it is based. But I do believe that empirical
(above all correlational) research can be done in a much more
critical and useful way. For instance I admire the work of Stern's
group (the Boston Change Process Study Group) on audiotaped
transcripts, in which they illustrate how much " sloppiness"
(fuzzy intentionalizing, unpredictability, improvisation,
variation, and redundancy) generates unpredictable and potentially
creative elements that contribute to psychotherapeutic change. I
think the Dodo bird would appreciate that his (her?) verdict
receives one more empirical support. Post-session questionnaires
might be less useful for such purposes, but I value them a lot as
precious tools for monitoring and documenting the process at
disposal of the local scientist. There is a great deal of
unpredictability in the psychotherapeutic process, and I believe
it is an "
inherent property of
intersubjective systems" (as the BCPSG puts it) in spite of
those who believe in manualized treatments. If this is the case,
let the therapy go its own way, but let us produce objective
material (questionnaires are literally objects that can be
intersubjectively examined, like audiotaped transcripts) to
document the process.
Continue
to read the listserv discussion during
February
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