Showing papers in "Psychotherapy in 1989"

Stages of change in psychotherapy: A follow-up report.

Abstract: The stages of change have already been well established with nonclinical populations. The present study was designed to cross–validate the Stages of Change Scales using a new clinical sample (N = 327). The principal component, internal consistency, and cluster profile analyses demonstrated a replica

Using the patient's plan to assess progress in psychotherapy.

Abstract: The value of adopting a case-specific approach to studies of psychotherapy has been noted in numerous recent reviews. However, few studies have assessed the suitability of therapist behaviors or have tailored process and outcome measures to the specific patients studied. The application of a particular kind of case formulation—a formulation of the patient's plan—to psychotherapy research is described. We review how patient plan formulations are used to study the effects of therapist interventions on patient progress (within-session change), and we describe how the plan formulations are used to develop individualized psychodynamic outcome measures (plan attainment).

Foundations for a systematic eclectic psychotherapy.

Abstract: Current textbooks of eclectic psychotherapy consist essentially of a collection of at best loosely integrated methods and techniques from various approaches to or theories of psychotherapy. The focus is upon including the disparate rather than the common elements of the major theories. This paper proposes that any true or systematic eclecticism must start from and be built upon the basic common elements of the major theories. Three of these common elements are empathic understanding, respect or warmth, and therapeutic genuineness. They are the core or essence of client-centered therapy, but it does not, however, have a monopoly on them Two topics are currently prominent in discussions of psychotherapy: (1) eclecticism, and (2) integration. These are not synonymous terms. Goldfried (1982b), and Goldfried and Newman (1986) provide useful histories of attempts at therapeutic integration. Current formulations of eclectic psychotherapy are not really integrative. They consist of a congeries of disparate techniques from many different--and often disparate and inconsistent --theoretical approaches, with little attempt at systematic integration. They pay little, if any, attention to the common elements in the major theories. The idea of common elements in different approaches has a long history, briefly reviewed here. Two classes of common elements are distinguished: (1) nonspecific elements, i.e., those elements not specifically related to the nature of client disturbance or therapy outcomes (the placebo), and (2) specific elements, directly related to client disturbance and therapy outcomes. The second group of common elements is proposed as a basis for a systematic eclecticism. THE RISE OF ECLECTICISM Eclecticism is not a new development. Most therapists were probably eclectic in the first half of the century, before the development of the current major theories. Psychoanalysis and its derivatives were the first theories to develop and most of those therapists who were not eclectic adhered to some form of psychoanalysis or psychoanalytic (dynamic) therapy. The so-called Minnesota point of view (Patterson, 1966, 1973, 1980) was an eclectic position. Thorne (Patterson, 1966, 1973, 1980, 1986) was perhaps the first to adopt the term eclecticism to designate a detailed, systematically developed position. The number and percentage of psychologists (therapists) who considered themselves eclectic during the 40s and 50s is not known. Thorne (Personal communication, June 2, 1967) gives a figure of zero for members of the American Psychological Association who identified themselves as eclectic, but the source of this figure is not known. Kelly (1961) reported a survey in which 40% of those responding in 1960 identified themselves as eclectic. Since then numerous surveys have found the percentage of psychologists (therapists) accepting the designation ranging from 30% to 65%, and fluctuating around 50% (Garfield, & Kurtz, 1974, 1976; Swan, & MacDonald, 1978; Larson, 1980; Fee, Elkins, & Boyd, 1982; Smith, 1982; Norcross, & Prochaska, 1982; Prochaska, & Norcross, 1983; Watkins, Lopez, Campbell, & Himmell, 1966; Mahoney, Norcross, Prochaska, & Missar, unpublished manuscript, 1986). It appears that the popularity of eclecticism may be declining; it is too early to sound the death knell for schools or theories. Eclecticism, while the most frequently chosen label by therapists (clinical and counseling psychologists), still claims less than 50% of those responding to surveys. The statement by Lambert, Shapiro, and Bergin (1986, p. 2020) that "...the vast majority of therapists have become eclectic in orientation" is an overstatement. An important point not addressed adequately in surveys is just what eclecticism means WHAT IS ECLECTIC PSYCHOTHERAPY? There is an increasing literature on eclecticism in psychotherapy, including the Journal of Integrative and Eclectic Psychotherapy. Various kinds of eclecticism have been proposed: theoretical eclecticism, technical eclecticism (Lazarus, 1981), prescriptive eclecticism (Dimond, Havens, & Jones, 1978), strategic eclecticism (Held, 1984), radical eclecticism (Robertson, 1979), and perhaps others. Most discussions of eclectic therapy involve combining two theories or approaches, usually psychoanalysis and behavior therapy (e.g., Wachtel, 1977). A number of books go beyond this, however: Beutler (1983), Garfield (1980), Hart (1983), Lazarus (1981), Norcross (1986a), and Palmer (1979), Prochaska and DiClementi (1984). The general-impression from all this literature is one of confusion. It is not clear just what eclectic therapy is. Those who call themselves eclectic appear to have little in common. They do not subscribe to any common set of principles. While they may not be anti-theoretical or even atheoretical, there is nothing that could be called an eclectic theory. Garfield and Bergin (1986) note that "there is no single or precise definition of an eclectic orientation...it is exceedingly difficult to characterize an eclectic approach in terms of either theory or procedures" (p. 8). Garfield's (1982) earlier characterization still holds: "Eclecticism is perceived as the adherence to a nonsystematic and rather haphazard clinical approach" (p. 612). Strupp and Binder (1984) make a similar statement: "The term eclectic, which many therapists use to describe their orientation and practices, is so fuzzy it defies definition" (p. xii). In effect, there are as many eclectic approaches as there are eclectic therapists. Each operates out of his or her unique bag of techniques, on the basis of his or her particular training, experiences, and biases, on a case by case basis, with no general theory or set of principles as guides. Prochaska and Norcross (1983) note that: "The need for theoretical orientation has been frequently recognized, but few, if any, adequate models of systematic eclecticism have been created... Beyond its conceptual relativity and personal appeal, eclecticism in its current state may not possess adequate clinical utility or validity for increasing numbers of therapists (p. 171)... The real challenge for synthetic eclectic therapists and theorists alike is to construct models of systematic eclecticism that have both empirical validity and clinical utility" (p. 168). A true eclecticism is neither nonsystematic nor haphazard. English and English (1958) define it as follows: "Eclecticism. n. In theoretical system building, the selection and orderly combination of compatible features from diverse sources, sometimes from incompatible theories and systems; the effort to find valid elements in all doctrines or theories and to combine them into a harmonious whole... Eclecticism is to be distinguished from unsystematic and uncritical combination, for which the name is syncretism." This definition of eclecticism is accepted for the purposes of this paper. In addition, the object of the paper is not to attempt to support another kind of eclecticism, but to suggest the basis for a single, all encompassing system, which is presumably the ultimate goal of all those concerned with psychotherapy. COMMON ELEMENTS IN PSYCHOTHERAPY The confusing state of eclectic (actually syncretic) psychotherapy is due to two factors: (1) in rejecting various theories, theory has been ignored or downplayed in the eclectic stance, and (2) in the attempt to include as many diverse methods or techniques as possible, there is little concern with their compatibility or orderly integration. Most eclectic approaches have been built upon the differences among the various approaches rather than upon similarities. Yet it has been recognized for at least fifty years (Rosenzweig, 1936) that there are basic common factors or elements in the diverse approaches to psychotherapy. Following Rosenzweig, numerous writers have suggested various common factors. The common factors noted have been numerous and varied. (Our concern here is with therapist variables only, and not with client variables.) At the simplest and most concrete level, therapy consists of two persons talking to each other. At the most abstract level, therapy is an interpersonal relationship, in which the therapist's personality (undefined) is the most important element. In between are such therapist behaviors or characteristics as status or superiority, authority, expertise, rapport, and support. More current terms are therapist credibility, trustworthiness, and attractiveness. Other writers have listed more specific techniques: catharsis, suggestion, reassurance, persuasion, advice, guidance, and direction. These are not present, however, in all theories or approaches. Still other factors noted are acceptance and understanding of the client, permissiveness, non-judgementalness, respect, honesty or genuineness. Frank (1982), who has been writing about common elements for nearly 25 years, has focused on a group of components more complex than simple lists, centering on his concept of therapy as a "means of directly or indirectly combating demoralization" (p. 19). His first component is "an emotionally charged confiding relationship with a helping person," involving the therapist's status or reputation but also including the communication of caring, competence, and the absence of ulterior motives (p. 19). Second, is a healing setting that heightens the client's expectation of help from a healer and that provides safety. Third, is "a rational, conceptual scheme or myth that provides a plausible explanation for the patient's symptoms and prescribes a ritual or procedure for resolving them" (p. 20). The fourth is "a ritual that requires active participation of both patient and therapist and that is believed by both to be the means of restoring the patient's health" (p. 20). Though developed in detail over a period of time, Frank's elements are abstract and not operationalized. Yet they have apparently had wide acceptance. They bear a striking resemblance to Fish's (

Integrating marital and individual therapy for incest survivors: A case study.

Abstract: The current climate in the marital and family field is one that fosters an integrative approach across treatment approaches and, more recently, across modalities. This impetus has arisen from the need to match the diversity and complexity of the phenomenon the therapist is trying to change with powerful, relevant, and flexible treatment strategies (Lebow, 1984). Various approaches to integration have been advocated in this field (Johnson & Greenberg, 1987&), the two most viable being a theoretical and clinical synthesis of two or more complementary approaches or the matching of specific interventions from different approaches to particular problems as they arise in therapy. The issue of how and when to integrate individual intrapsychic and interpersonal systemic change strategies seems to be particularly pertinent at the present time (Nichols, 1987).

Therapist complementarity as a function of experience and client stimuli

Abstract: Degree of therapist complementarity is examined in responses made to client statements which varied on the three dimensions of directness, power, and type of affect as it varied over therapist experience level. Professional therapists demonstrated significantly lower complementarity and different complementary patterns over the three stimuli dimensions than did student therapists when client statements were indirect. Professionals showed the lowest levels of complementarity only for the hostile-dominant stimuli. These results are described with respect to therapist training and assessment of complementarity.

Eclecticism in psychotherapy: Is integration possible?

Abstract: Despite efforts toward integrating differing approaches, little progress has been made in developing a single, comprehensive system of psychotherapy. A major problem to such integration arises with the existence of two basically incompatible or irreconcilable views of human nature and of related philosophies, theories, and practices of psychotherapy. The currently popular paradigm is questioned; a paradigm change is suggested, although the author is pessimistic about its occurrence. Interest in eclectic psychotherapy, and in the integration of various systems of psychotherapy, have been increasing in recent years. Goldfried and Safran (1986, p.463) note that \"the indications are very clear that the field of psychotherapy in the 1980s is highlighted by a rapid developing movement toward integration and eclecticism\". The extent of this interest is indicated by Norcross's (1986) edited book. Included are chapters by authors of the major eclectic positions including Beutler (1983, 1986), Garfield (1980, 1986), Hart (1983, 1986), Lazarus (1981, 1986), and Prochaska and DiClementi (1984, 1986). Goldfried and Newman (1986) provide a historical background, and Dryden (1986) Goldfried and Safran (1986), Messer (1986) and Murray (1986) provide critical comments. Perusal of these presentations and other writings, in the process of preparing a paper on \"Foundations for a Systematic Eclectic Psychotherapy\" (Patterson, 1989) suggested a number of issues that have not been adequately recognized or considered. 1. The objective of any movement toward eclecticism or integration in psychotherapy must be the development of a single comprehensive system of psychotherapy including philosophical and theoretical foundations, the derivative principles guiding practice, and the implementation of these principles. Norcross (1986b, p.11) notes that \"the promise of eclecticism is the development of a comprehensive psychotherapy based on a unified and empirical body of work\". At the present time, nothing of this sort has been proposed (with the exception of my paper). The existing proposals for an eclectic psychotherapy are independent of each other. Each incorporates limited combinations of methods, strategies and techniques from existing theories or approaches, with little attention to any philosophy or theory. What appears to be happening is the development of a number of new approaches on the way to becoming schools. Dryden (1986, p. 374), evaluating the contributions in the Norcross volume, writes: \"There is little evidence at present that the contributors...are drawing upon one another's work to a significant degree. This surprises and troubles me.\" Goldfried and Safran (1986, p. 646) make the same point: \"Although there is an increasing acknowledgement of the need to develop a more integrative approach to psychotherapy, we are far from having any consensus as to exactly what that approach should be...there exists a real danger that...we may ultimately end up with as many eclectic models as we currently have schools of psychotherapy...\" It seems that the present situation does not provide any basis for optimism about achieving the goal of a comprehensive unified system. Norcross (1986, p. 6) writes: \"The ideal of integrating all available psychotherapy systems is not likely to be met.\" London (1988, p. 10) recognizes that integration may not be possible but does not suggest any reasons: \"Integration involving conceptual continuity across all techniques is still missing, and it is missing for a good reason, I think. It may not be possible.\" 2. Current eclectic attempts neglect theory. Murray (1986, p. 405) writes: \"in the contributions of the eclectic therapists in this volume, theoretical orientations play a relatively small role.\" He continues: \"However, true integration requires a coherent theoretical structure, which does not yet exist. We are still waiting for our theoretical integration.\" (p. 413). 3. Not only is theory neglected, but there is little concern with research support. Eclectic writers emphasize the empirical bases of their proposals, but this is essentially nothing more than their own individual clinical experience, or at most one or a few limited studies whose results agree with their system. Also, as Dryden (1986, p. 373) notes, the research literature is interpreted differently by different authorities. Clearly, we are at a very early stage in the development of a truly systematic eclectic psychotherapy. Many writers have noted obstacles in the way. The nature and seriousness of these obstacles do not seem to be adequately acknowledged or recognized. The result is that optimism about progress is perhaps greater than is warranted. Two major problems are considered. INCOMPATIBLE THEORETICAL ORIENTATIONS The neglect of theory appears in part to represent the apparent perception of many writers that (a) theory is not important in the practice of psychotherapy, or (b) there are no irreconcilable elements in the various theories, or (c) theories are too abstract and complex to attempt to integrate. Goldfried's proposal that integration should be attempted at the level of strategies rather than at the level of techniques or theory (Goldfried, 1980; Goldfried & Padawer, 1982; Goldfried and Safran, 1986), however, is based on the belief that \"In the search for commonalities, it is unlikely that we can ever hope to reach common ground at either the theoretical or the philosophical level (Goldfried, 1980, p. 984). Further, Goldfried and Safran (1986, p. 468) suggest that \"There is always the danger that comparative analysis [of the psychotherapy process] at the higher levels of abstraction [philosophical and theoretical] will obscure important similarities in [the] psychotherapy process, both because of differences in theoretical language and because of abstract philosophical differences that never really translate into clinical reality.\" But focusing on strategies rather than theories does not avoid the theoretical incompatibilities. Strategies involve goals, and goals involve theory. Casting the therapist as a strategist puts him/her in the role of expert, the planner and director of therapy. (Strategies also imply conflict-generals plan strategies in war; and chess players plan strategies in the game of chess). While this concept of the therapist is widely, if not generally, accepted, it is not the only concept of the therapist. Thirty years ago the writer suggested that there are two conflicting approaches to psychotherapy (and to human relations in general) (Patterson, 1958, 1959). One approach, the manipulative approach, casts the therapist as an expert, controlling and directing the therapy process. The second, or understanding, approach places the locus of control with the client, with the therapist facilitating the therapy process through empathic understanding. London (1964) has also noted these two major approaches to psychotherapy. These two approaches represent two different views of human beings, described by Allport (1962) as on the one hand reactive beings, controlled from without (behaviorism) or within (psychoanalysis), and on the other hand as a being in the process of becoming. That these two opposed, and irreconcilable, approaches still exist was apparent at the 1985 Phoenix Conference at which 26 of the world's leading therapists lectured and demonstrated before an audience of some 7000 (Zweig, 1987). The conference was a veritable Tower of Babel. Yet Margo Adler, reporting on the conference for PBS radio, said that there were two different kinds of therapists present: the manipulators and the enablers, or, as more commonly termed, the facilitators. Until we can reach agreement on the nature of human beings, no agreement on a philosophy or theory of psychotherapy is possible. And until some agreement on philosophy and theory is achieved, no agreement on the practice of psychotherapy is possible. THE PARADIGM FOR ECLECTIC PSYCHOTHERAPY The basis for eclectic practice is the contention that different clients and different problems require different treatments. This paradigm was stated clearly by Paul (1967, p. 111): \"In all its complexity, the question toward which all outcome research should ultimately be directed is the following: What treatment, by whom, is most effective for this individual with that specific problem, and under which set of circumstances.\" Krumboltz (1966) had phrased it: \"What we need to know is which procedures and techniques, when used to accomplish what kinds of behavior change, are most effective with what kind of client when applied by what kind of counselor.\" Blocher (1968, p. 16) writes: \"The old question of 'Is counseling effective?' or 'Which counseling theory is correct?' are (sic) largely seen as rhetorical. They give way to questions of 'What treatment in the hands of which counselors can offer what benefit to particular clients?'\" Strupp and Bergin (1969, pp. 19-20), in an extensive review of research in psychotherapy, wrote: \"We have become convinced that the therapy of the future will consist of a set of specific techniques that can be applied under specifiable conditions to specific problems, symptoms or cases...the problem of psychotherapy research in its most general terms, should be reformulated as a standard scientific question: What specific therapeutic interventions produce what specific changes in specific patients under specific conditions?\" This has been the model for much of the research by behaviorists in psychotherapy. Some 20 years later, no progress seems to have been made in specifying different treatment for different clients with different problems. A consideration of the requirements for adequate research following this paradigm should reveal the basis for lack of success. The model requires (a) a taxonomy of client problems (a reliable, relevant diagnostic system), (b) a taxonomy of therapist qualities, (c) a taxonomy of therapeutic interventions