21ST-CENTURY PSYCHOTHERAPIES INTRODUCTION
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21ST-CENTURY PSYCHOTHERAPIES
Other men are lenses through which we read our own minds.
Ralph Waldo Emerson (1850)
Psychotherapy, as far as it leads to substantial bebavior change, appears to
achieve its effect through changes in gene expression at the neuronal level.
Eric Kandel(1996)
This book surveys a diverse set of effective psychotherapies. Each represents a vision of
the Human as well as a set of distinct treatment procedures for addressing the emotional
distress and the accompanying behavioral and cognitive problems that drive people to
seek help. As one reviews the evolution of this textbook through nine editions and the
theories of personality development that underpin each of the therapeutic modalities
treated within it, it's evident that these modalities have an increasingly short half-life.
Entire schools of psychotherapy have undergone dramatic change, some more rapidly
than others---and some have virtually disappeared (e.g., Transactional Analysis,). The
editors of this book continue to showcase several therapies that have their origins in
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the early 20th century, but they do this because these earlier therapies have evolved to reflect changes in the science of developmental psychology and have continually improved their clinical effectiveness. Therapies of more recent vintage have been added, which, although built on strong historical foundations, would strike even psychotherapists of the 1960s and 1970s as novel if not strange. In any event, to understand where We are heading, We need to know where psychotherapy started and how it has changed. The following section addresses this matter.
Historical Foundations of Psychotherapy
From the origins of recorded history, humans have sought means to remedy the mental disorders that have afflicted them. Some of these remedies were (and continue to be) patently unscientific, if not ineffective, such as the ceremonial healing rituals found in shamanistic societies. Pre-Christian, temple-like asklepeia and other retreat centers of the eastern Mediterranean region, using religio-philosophical. lectures, ineditation, and simple rest, competed with secular medicine to assuage if not remedy psychological disorders. This latter stream of psycho-physiological treatment, in which Hippocrates Worked, was surprisingly scientific. Hellenist physicians, through their empirical studies, understood that the brain was not only the seat of knowledge and learning but also the source of depression, delirium, and madness. indeed, he Wrote, “Men ought to know that from nothing else but the brain come joys, delights, laughter and sports, and sorrows, griefs, despondency, and lamentations . . . and by the same organ We become mad and delirious, and fears and terrors assail us . . . all things We endure from the brain when it is not healthy” (5th c. B.C.E., quoted by Stanley Finger, 2001, p. 13). Hippocrates himself insisted that his students address illnesses by natural means. He repudiated the popular notion that such illnesses as seizures were divine” and should be treated by appealing to and placating gods. Although the Hippocratic tradition endured uninterruptedly to the time of his renowned disciple Galen, who lived six centuries later, psychotherapy in its present guise did not clearly emerge until the 18th century.
The Unconscious
The reader will find that the construct unconscious plays a salient role in certain chapters of this volume, especially those that have a psychodynamic character, but it was also a key construct in the psychotherapies that emerged in the 19th century. The scientific study of the unconscious is commonly thought to have started with the renowned polymath Gottfried Wilhelm Leibniz (1646-1716). Leibniz studied the role of subliminal perceptions in our daily life (and, incidentally, coined the term “dynamic” to describe the forces operative in unconscious mentation). His investigations of the unconscious were continued by Johann Friedrich Herbart (1776-1841), who attempted to mathematicize the dynamics describing the passage of memories to and from the conscious and the unconscious. Herbart suggested that ideas struggle with one another for access to consciousness as dissonant ideas repel one another and associated ideas help pull each other into consciousness (or drag each other down into unconsciousness). Leibniz and Herbart are examples of 17th- and 18th-century scientists who attributed significance to an understanding of the unconscious in their work (Whyte, 1960).
Mesmer and Schopenhauer. Two of the most influential and creative thinkers in the early 19th century were Franz Anton Mesmer (1734-1815) and Arthur Schopenhauer (1788—1860). Their impact can be seen in the psychiatric literature that evolved into the full-fledged systems of Pierre Janet, Sigmund Freud, Alfred Adler, and Carl Gustav Jung. Thomas Mann (a Nobel laureate in literature) stated that in reading Freud, he had
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an eerie feeling that he was actually reading Schopenhauer (1788-1860) translated into a later idiom (Ellenberger, 1970, p. 209).
Mesmer and his disciple the Marquis de Puységur, regarded as the pioneers of hypnotherapy, effectively discredited the exorcist tradition that had dominated preEnlightenment Europe (Leahey, 2000, pp. 216-218). That there were many quaint and unsubstantiated hypotheses in the Mesmerian system does not diminish the fact that the notion of rapport between therapist and patient, the influence of the unconscious in shaping behavior, the personal qualities of the therapist, spontaneous remission of disorders, hypnotic somnambulism, the selective function of unconscious memory, impatients’ confidence in treatment procedures, and other common factors in our current therapeutics armory can be traced back to this period in European history.
Three distinct streams of investigation into how the mind works emerged in the 19th century. The contributors to these three streams were (a) systematic, lab-bench empiricists, (b) philosophers of nature, and (c) clinician—researchers. A multitude of psychotherapies were spun out from these investigations.
Psychotherapy-related Science in the 19th Century
The Natural—Science Empiricists
Some of the greatest scientists of the 19th century, such as Gustav T. Fechner (18011887) and Herman von Helmholtz (1821-1894), conducted seminal research in the area of cognitive science. Fechner’s work tapped into and overlapped with the investigations of Herbart. Fechner began with the distinction between the theaters of the waking and sleeping states—and especially the dream state. That the unconscious existed as a realm of the mind was evident even to the untutored farm laborer. Anyone who had ever struggled to recall a rnemory—and succeeded——knew that he or she retained knowledge that Was not always readily accessible. This knowledge had to reside sornewhere. In the late 1850s, Fechner, in his psychophysics experiments, attempted to measure the intensity of psychic stimulation needed for ideas to cross the threshold from the unconscious to full awareness, as Well as the intensity of the resultant perception. Fechner’s studies reverberated throughout Europe, and the reader may unknowingly resonate to his findings not only in Freud’s writings (Freud quoted him in several of his works) and the chapters of this book but also in those of myriad other contemporary theorists and practitioners, most notably the Gestaltists and (Milton H.) Ericksonians.
Helmholtz, another experirnentaiist, “discovered the phenomenon of ‘unconscious inference’,” which he perceived as a kind of instantaneous and unconscious reconstruction of what our past taught us about the object” (Elienberger, 1970, p. 313). Wilhehn Griesinger, Joannes von Muller, and many other such experirnentalists and brain scientists dominated the academic scene of Vienna, Heidelberg, Leipzig, and other Germanlanguage universities and institutes, making many contributions that infused the work of later psychodynamicists.
The spirit and approach of these lah-based scientists resounded throughout Europe and in large part constituted what became known there as the somatzlker (organicist) tradition. Several of Freud’s mentors, such as Ernst Briicke (1819-1892) and Theodor Meynert (1833—1892), were organicists. Although the organicists Worked feverishly throughout the century to find solutions to psychiatric disorders, Emil Kraepelin on the cusp of the 20th century finally conceded defeat, admitting that 50 years of hard bench work had given medicine few tools for curing psychiatric disorders (Shorter, 1997, pp. 103, 328). He turned his attention to classifying diseases, meticulously describing
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them, schernatizing their course, and establishing benchmarks for prognosis. This provided an opportunity for the pxyc/aiker (those who were convinced that only a psychological approach to mental illness would prove effective) to gain prominence. The work of all the brass-instrument methodologists and empiricist dream scholars still pales in significance by comparison with the influence of the psycho-philosophical Writers of the first half of the 19th century.
The philosophers of nature had a much greater, long-term influence on the development of the psychotherapies described in the following chapters of this book than did laboratory-based scientists. These philosophers can be historically situated in the same school of thought that nurtured Schiller and Goethe. They were Romantics in the philosophical sense, firmly rooted in nature, beauty, homeland, sentiment, the life of the mind, and of course, the mind at its most enigmatic: the unconscious. Arthur Schopenhauer, Carl Gustav Cams, and Eduard von Hartmann were among the most notable of this group.
Carl Gustav Carus (1789—1869), though largely unread today, can justifiably be singled out in a hook on psychotherapy because he developed one of the most sophisticated schemas that exist for the unconscious (see Ellenberger, 1970, pp. 202-210). Catus speculated that there are several levels to the unconscious. When humans interact, all levels of the unconscious as well as the conscious interact. To extrapolate to the clinic, when patient and therapist are at work, the conscious of each speaks to the unconscious as well as to the conscious of the other. But further, the unconscious of each speaks to the conscious as well as the to unconscious of the other. Needless to emphasize, both are communicating with each other in paravocal, nonverbal, organic, and affective modes of which both participants are largely unaware. In this perspective, boil) the therapist and the patient engage, willfully or not, in transference and countertransference (see Dumont 81 Fitzpatrick, 2001). Nonlinear messages are systemically (often simultaneously) sent in all directions. What Carus taught us is that transference occurs at an unconscious level.
Before Carus, Schopenhauer (1819) published “The World as \Will and Idea.” This masterpiece of the Western canon, once it caught on, provided ideational grist for generations of psychological researchers who followed. It inspired those psychologists who were children of the Philosophy of Nature and had embraced (or resigned themselves to) nonhiological methods for curing the fashionable disorders of the day-—-even those disorders that today would he classified as (DSM) Axis I disorders. Schopenhauer’s book was in large part a treatise on human sexuality and the realm of the unconscious. His principal argument was that we are driven by blind, irrational forces of which we are largely unaware and that we know things that we are unaware that we know. His irrationalist and pansexual view of human behavior and mentation was deterministic and also pessimistic (see Ellenberger’s [1970] analysis, pp. 208—210). Schopenl1auer’s thoughts influenced the psychology of many later thinkers, not least Friedrich Nietzsche and Sigmund Freud.
The tracts of Schopenhauer and Carus set the epistemological stage for von Hartrnann’s and Nietzsche’s influential Writings on our tacit cognitions, which they believed drove the daily, unreflective behavior of people. In Nietzsche’s view, humans lie to themselves even more than they do to each other. What We consciously are thinking is “a more or less fantastic commentary on an unconscious, perhaps unknowablc, but felt text” (cited in Ellenbcrgcr, 1970, p. 273). He developed notions of selfideception, sublimation, repression, conscience, and neurotic guilt. Cynic par excellence Nietzsche averrecl that every complaint is an accusation and every
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admission of a behavioral fault or characterological flaw is a subterfuge to conceal more serious personal failures. In brief, he unmasked many of the defense mechanisms that humans employ to embellish their persona and self-image. Nietzsche, in his unsystematic and aphoristic Way, cast a long shadow over the personology and psychotherapies of the 20th century.
The C1inician——Researchers
In the nascent clinical psychology of the 19th century, a great number of gifted clinicians made discoveries and innovations in their clinical practice that had implications for psychotherapy generally and for the development of theories of personality as Well. Some were humble practitioners like the celebrated hypnotherapist Arnbroise Liébault, other great scholars like Moritz Benedikt (1835-1920), whose work in criminology, psychiatry, and neurology won the admiration of Jean-Martin Charcot. Benedikt developed the useful concept of seeking out and clinically purging “pathogenic secrets,” practice that Jung later made an essential element of his analytic psychotherapy. Theodore Flournoy, Josef Breuer, Auguste Forel, Eugen Bleuler, Paul Dubois (greatly admired by Raymond Corsini), Sigmund Freud, Pierre Ianet, Adolf Meyer, Carl Gustav Jung, and Alfred Adler all made signal contributions to the science of psychotherapy. Though many of their contributions have outlived their usefulness, the many offshoots of their findings and systems can be traced in clinical psychotherapy and in other psychological disciplines.
A corollary of the notion that psychotherapies are in constant evolution is the recognition that clinicians have often perpetuated the strategies and techniques they learned in their graduate professional programs, dated though they may have become, rather than learning and developing important new principles and procedures through their professional practice and diligent reading of the literature in their specialty. Remaining at a fixed stage of one’s continually evolving profession is not a desirable outcome of training, for, to paraphrase an aphorism from sport psychology, practice makes permanent but not necessarily perfect. Improving our performance of an outdated or largely flawed technique is not a clinical desideraturn.
Chapters 2 through 15 of this volume represent scientifically recognized advances over what preceded them. Like all current and major psychotherapies, they have all emerged to a greater or lesser degree from the historical matrix described above. Even the contemplative therapies described in chapter 13 have their roots not only in the ancient traditions of the Middle and Far East but also in those of the Near East and the asklepeia of Hellenic Greece.
THE IMPACT OF THE BIOLOGICAL SCIENCES
When patients1 learn new ideas, Whether true or false, whether in the clinic or in the course of daily life, concomitant alterations of the brain occur (see, e.g., LeDoux’s [Z002], Synaptic Self). Every encounter with our environment causes a change Within us and in our neural functioning. Moreover, education implies permanence. Once skills and ideas are truly learned and lodged in permanent storage, it is difficult if not
1 Throughout this chapter we have used the term patzkvzt, which etymologically implies suffering and characterizes most people who seek therapy. It is a derivative of a Latin verb that means to endure a painful situation. In the 8th edition of this book, Ray Corsini noted the disciplinespecific connotations of patient and client, the former for medical contexts and the latter for his private practice.
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impossible to unlearn them. Given the solution to a puzzle, taught the secret of cracking a safe, or having developed the skill of riding a bicycle, one cannot unlearn that knowledge. Neuronal decay and lesions can, of course, undo memory and occur to a certain extent in aging and, catastrophically, in strokes, illness, or violent accidents. The task of the therapist in most cases is to help the patient fashion alternatzbe and future memories, supported by newly learned motivational schem as.
Klaus Grawe (2007), in his important book Neuropsyc/vothempy: How the Neurosciences Inform Psyc/902‘/aempy, noted that “Psychotherapy, as far as it leads to substantial behavior change, appears to achieve its effect through changes in gene expression at the neuronal level” (p. 3, citing Kanclel, 1996, p. 711). Further embedding patients in their dysfunctional past by prodding them to ruminate about that past does not erase their painful memories nor their penchant for dwelling on these memories. Nor does it teach. them more adaptive patterns of behavior. Therapists teach patients how to avoid dysfunctional, harmful behavioral routines and maladaptive habits. Effective therapists also help their clients develop alternative skills (social, interpersonal, self-disciplinary, and technical) that will advance their well-being and that of others with whom they interact. The neurosciences have demonstrated that neuronal~ restructuring, Which occurs in all learning processes, enables the adaptive changes in affect, behavior, and mentation that are the core objectives of psychotherapy (ct. Dumont, 2009; 2010).
A neurological perspective on psychotherapy does not exclude attention to changing clients’ environment or introducing constructive environmental stimuli into their lives. On the contrary, even minor novelties in clients’ lifestyle can have enormous consequences in the way they perceive and experience themselves. We now know that effective therapists and their clients can optimize desirable outcomes by epigenetically triggering the expression of z'mmedz'ate~earZy genes (IEGs) through exposure to nurturant social events (Giintiirkiin, 2006). (Epigenetz'c5 refers to the expression of certain genes that results from their activation by specific but common environmental events.) Culture generally and one’s immediate family specifically function as genetic enablers. Such epigenetic effects can operate for better or for Worse, depending on the quality of the experiences. In brief, it is the complex bio-cultural matrix of the organic and the environmental that co-construct our way of being and our potential for growth (Baltes, Renter-Lorenz, Rosier, 2006).
ORGANICISTS AND DYNAMICISTS: CLASHING
STANDPOINTS
Readers will immediately recognize the potential for cultural confrontations in these propositions. However, our view is that confrontation is neither necessary not useful. The ancient animosity between the somatiker and the psyc/yiker, the psychopharrnacological organicists and psychodynarnicists, the behavioral geneticists and the cognitive-behaviorists can be resolved through a systemic integration of the many variables that are at play at any moment. Indeed, such integration is necessary. To ignore organic or environmental variables in one’s treatment of one’s clientele is to neglect essential aspects of the whole person, and to treat all affective disorders as if there were no organicity in the causal skein of variables that brought them about is . an ancient error.
One example of this error is ignoring patients’ medication histories. Kenneth Pope and Danny Wedding (2010) discuss the danger inherent in neglecting to monitor patients who are taking psychotropic medication. Patients need to be pharmacologically guided and their experiences between sessions closely monitored. Medicating patients
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for psychological purposes requires preset clinical objectives and conscientious ongoing assessment of progress. Grawe (2007) stated:
From a neuroscientific perspective, psychopharmacological therapy that is not coordinated with a simultaneous, targeted alteration of the person’s experiences cannot be justified. The widespread practice of prescribing psychoactive medication Without assuming responsibility for the patient’s concurrent experience is, from a neuroscientific view, equally irresponsible. . . . The use of pharmacotherapy al0ne——in the absence of the professional and competent structuring of the treated patient’s life eXperience——is not justifiable . . . (pp. 5-6)
Nurture is profoundly shaped by nature. Similarly, aspects of our nature (that is, our genetic inheritance) are epigenetically expressed for better or for worse by the kinds of experiences to which WC are subjected throughout life. This explains in part why, among identical twins, one can become severely diabetic while the other does not. In this perspective, therapists become responsible to some degree for both the natural and nurturant components of the patients’ lives that come under their purview.
Evolutionary Biology and Behavioral Genetics
plications for psychotherapy. Evolutionary psychology will likely further clarify many of the temperamental traits that therapists need to understand to be effective. Steven Pinker (2002) has extensively documented the principle that all humans share the same, unique nature. If we exclude anomalous genetic mutations, the normative stance of all clinicians treating a patient is that they are dealing with an organism struck from the same genetic template as themselves.
Evolutionary psychology is closely related to the field of behavioral genetics, another discipline that will have an impact on the therapeutic modalities that clinicians of the future will assuredly develop. This discipline will shine a focused light on the lawfulness that governs the human genome and the biopsychosoeial regularities that occur in the course of one’s life. There are more regularities, that is, universal behavioral traits, than We have traditionally imagined (see Brown, 1991). While accepting the parameters established by our genetic inheritance and the regularities our genes prescribe for our human interactions and life course, clinicians will still need to treat the idiosyncratic dysfunctions their patients reveal to them. Moreover, as suggested above, psychotherapy will involve monitoring the situational variables and events that can trigger the expression of latent genes. Finally, the related fields of molecular genetic analysis, cognitive neuropsychology, and social cognitive neuroscience, which are advancing at an impressive rate, will inevitably infiltrate our porous integrationist models of helping.
Demographics
In this 9th edition of Current Psyc/90trlvempz'es, a new chapter is dedicated to current approaches to multicultural psychotherapy, This initiative is not simply a reflection of the self-evident importance of cultural factors in counseling and psychotherapy that have been developing in recent decades. It is also a reflection. of the changing demographic character of the planet, the human tides that are swirling about the previously distant continents of the globe, the tightening communicational network of masses of people engaged in armed conflict, research, diplomacy, and higher education, and
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the internationalization of professional psychological counseling. Although chapters on jungian psychotherapy (Chapter 4), existential psychotherapy (Chapter 9), and, most notably, contemplative psychotherapies (Chapter 13) have dealt heretofore with the ethno~cultural variables implicated in the treatment of diverse ethnic populations, at new chapter (Chapter 15) will be dedicated exclusively to this approach.
The complexities involved in multicultural counseling are incomparably greater than those involved in conducting therapy in a homogeneous culture where each member of the therapeutic dyad springs from the same ethno-cultural background. Where the patient and the therapist are solidly grounded in different traditional cultures, it matters if the “authority” figure is a member, say, of a minority, nondominant culture or the dominant, majority culture. In marital counseling, the difficulties multiply like fractals if the couple seeking help is biracial. In this case, the matrix of interactive variables becomes even more complex if the therapist/ counselor unknowingly identifies with one spouse rather than the other. Gender by culture permutations add another layer of systemic interactions. And of course it is not enough to simply acknowledge one’s differentness. Counselors are never fully aware of how different they are from the clients sitting across from or beside them for the simple reason that they are never fully conscious of the dynamics driving their own reactions to the client’s socially conditioned sensitivities. Much of therapists’ mentation operates beyond awareness, for their own cognitive and affective structures are intenneshed in the invisible, bottomless depths of their unconscious.
Cantonese speakers counseling Cantonese speakers in Hong Kong face a different set of parameters and challenges than Hispanic counselors in San Diego counseling other Hispanics. The philosophical and socio-economic differences that characterize men'1~ bers of the same society will determine the suitability of nonindigenous psychotherapies that are most congenial to both of them. But within homogeneous non-Caucasian populations, there is the same constellation of contingencies that confront Euro-American peoples. Iob stresses, finances, physical illness, personal history, family dynamics, personological variables of genetic and environmental origin, even the Weather will all affect what happens between a therapist and a client.
Language and Metaphor
Language, behavioral mannerisms, local and national poetry, metaphor, and myth are the instruments that shape the structures of our mind (see, for example, Lakoff 8: Johnson [1980] in Memp/901'; We Live By). Popular metaphors permeate all aspects of human thought. They ultimately shape a nation’s culture and collective personality. Those who are not familiar with these elements of their clients’ culture will find it difficult to enter the labyrinthine recesses where their ancestral and self-made daemons (some benevolent, some hurtful) resicle.
All therapists have clinical stories they can tell of mistakes they have made by the innocent use of a metaphor, a careless juxtaposing of questions, a refusal of a courtesy, or insensitivity to a taboo of their client’s culture. Painfully, their former friends and patients have left, never to return, with hardly a of explanation. For this reason, it has often been proposed that psychotherapies need to be incligenized. Rather than exporting Euro~Arnerican psychotherapies, say, to China, some would encourage Chinese healers to develop psychotherapies that reflect their philosophies, values, social objectives, and religious convictions. Yang (1997, 1999), for example, has suggested that Chinese counselors can more easily help resolve the paradoxes and dilemmas that characterize Chinese village, family, and personal life than non-Chinese can. Likewise, Hoshmand (2005 , p. 3) avers that “indigenous culture provides native ways of knowing what is salient and congruent with the local ethos and what are credible ways of addressing human prohlems,” a view supported by Marsella and Yarnada (2000). Similarly,
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Cross and Markus (1999) note that “the articulation of a truly universal understanding of human nature and personality . . . requires the development of theories of behavior in the indigenous psychologies of Asian, Latin American, African, and other non-Western societies” (p. 381). ~ The complex issues that we have alluded to here will be more fully addressed in
Chapter 15.
Division 12 (1995) of the American Psychological Association (APA) established a Task Force on Promotion and Dissemination of Psychological Procedures to grapple with the issues of empirically based treatments (EBTs), Since then there has been a flood of research conducted to demonstrate the scientific validity of those therapies their partisans espouse. As in earlier editions of Current Psyc/oot/oempies, the contributors to this book have wrestled with this issue. There are a number of serious fault lines in the terrain defining this debate, and although they have all been addressed by the professions serving the mental health needs of society, they still constitute threats to clinical credibility.
Psychotherapy: An Art or a Science
Patients typically work in session with one therapist for 50 minutes a Week but are exposed for the rest of the Week to innumerable contingencies outside the clinic that can confound their fine-tuned plans and firrnest resolve. Many of these contingencies are unforeseen and beyond their control. Paul Meehl (1978) called these random events context-dependent ytoc/aastologicals (pp. 812-814); they are a tangle of variables internal and external to the person that intertwine with job stresses, financial concerns, troubled children, angry spouses or in-laws, difficult colleagues, bad weather, life-threatening illness, dubious insurance claims, and the forgotten baggage of personal history and past defeats. Each patient has a unique set of such variables, but to make the situation even more complicated, they are often afflicted by a number of distinct disorders. This comorbidity complicates the categorization of disordered patients for purposes of validating therapy for them (Bcutler 8c Baker, 1998). For many practitioners and onlookers, the science of prognosticating outcomes in psychotherapy inspires as much confidence as predictions of stock market fluctuations. There is simply too much. opacity in the universe of variables, known and unknown, to make confident prognoses.
spontaneity and Intuition: “Throw-Ins”
Readers of the chapters of this book will be faced with clients who present complex puzzles to them, each client manifesting varying degrees of anxiety, coping skills, and emotional stability—and often with no clear idea what their treatment will consist of nor how effective this expensive service likely will be. Long before clinical interns enter that arena, they will need to have made some multilayerecl existential choices: Whether (or not) to become artisanal therapists, manuahhased “craftsmen,” or complex humanistic variants between these two extremes. Yalom (1980) Wrote about a cooking course he once took with an Armenian chef. She could not speak English, not could Yalom or other students speak Armenian. The students learned by watching, like so many Inuit children. Besides noting the main ingredients, Yalorn observed that as the pots and skillets were from counter to stove, a variety of spices were tossed in—a pinch of this and a pinch of that. “I am convinced,” he Wrote, “those surreptitious thr0w~ins made all the difference” (p, 3). He likened this process to psychotherapy. Often unknown to therapists, it’s their unscripted “throw-ins” that can make all the difference.
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manual
Spontaneous, unplanned throw-ins are hardly a basis for a science of psychotherapy. Doing psychotherapy in this manner makes it more like a craft, or at its pinnacle——as Yalom and Josselson do it—-an art. Even repeatedly demonstrating that one can improve client well-being and achieve therapeutic ohjectives by a manualizecl series of interventions does not explain how the variables have caused the outcome. Intensive research has been conducted in the last decade precisely to identify the mechanisms that are bringing about change. Although ambitious programs of process research, as distinguished from outcome research, are being conducted (see, e.g., Norcross 8c Goldfried, 2005), these causal links nature are not yet fully understood. Such understanding will only surface when We have a mature-neuroscience that can describe
the mechanisms involved. This problem is obviated for those who are only seeking
manualized approaches to therapy, that is, sets of sequential, algorithrnized steps for proceeding through phases of therapy (see Prochaska, N orcross, 8: DiClen1ente, 1995, for one cogent model).
There are several practical advantages to rnanualized psychotherapy. Engineering therapy in the guise of an architecture of stages or building blocks makes sense pedagogically. One proceeds from the known to the unknown and untried in a methodical, stepwise fashion, clearly specifying layered objectives and mobilizing the personal, social, and institutional 1“tlSOl/JICES that are so useful—and so often necessary. These processes through which the patient can be guided are amenable to various configurations. The chapters of this book (2 through 15) have been structured in such a way that the enterprising student can design a manual for each using the elements as they are presented.
obstacle
The sheer number of potent client and personological variables that must be considered when computing the outcome variance of a procedure dwarfs the influence of the technique. Citing numerous studies, Michael Mahoney wrote in 1991 “the person of the therapist is at least eight times more influential than his or her theoretical orientation and/ or use of specific therapeutic techniques” (p. 346). Norcross and Beutler (2008)
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stated that there are “tens of thousands of potential permutations and combinations of patient, therapist, treatment, and setting variables that could contribute” to improving treatment decisions (p. 491). They noted the earlier studies of Beutler and colleagues in which the latter conducted various analyses of these multitudinous variables with a sample of depressed patients. They reduced “tens of thousands” to a manageable number, trusting that the loss of specificity in their constructs would not overshadow the utility of their generic approach. This is analogous to the task undertaken by Allport and Qdbert (1936) and several generations of trait psychologists who followed them, who reduced 18,000 personality descriptors to a handful of core personality factors using the factor analytic techniques developed largely by Raymond B. Cattell.
The irntnensity of the task dawns on us when we consider the hundreds of other DSM disorders that call for varied treatments on the one hand and Meehl’s innumerable random events on the other. The complex and changing context of our patients’ daily lives is like a headwind that keeps pushing us back toward Yal0m’s kitchen and the critical importance of “throw-ins.”
The pursuit of what works is more important to pragmatic species like /some sapiem than the pursuit of why it works. This is especially true of psychotherapy, which is an applied and very practical science. Like wave and particle theories in the physics of light, art and science in psychotherapy are not incompatible paradigms. Both are valid, and elements of both appear in every clinical session. As unanticipated material comes to light, all clinicians to one degree or another rely on intuitive inspiration and creative imagination in deciding what to do next in therapy.
Some therapies, such as behavioral and cognitive therapies, are more amenable to manualization than others such as existential psychotherapy but ought not to be preferred simply for that reason. On the other hand, the manualization of therapies must not be caricatured simply as a cookbook approach to treating disorders. The variables and the random events that continually pop up in a patient’s life and complicate therapists’ best-thought-out plans require adjustment and compromise. Therapeutic judgment and creativity are always called into play. Pursuing the mirage of a blueprint that unfolds seamlessly from start to finish entails a loss of therapists’ time and effectiveness and drains patients’ emotional and financial resources. There is room in evidence-based therapies and tnanualizecl therapies for the poetry, spirituality, spontaneity, sentiment, free Will, even the mystery and romance of human. self-discovery and growth that both patients and humanistically inclined therapists crave. There should be no tension between getting better and feeling better. In fact, like butter in the batter, affect and reason are as inseparable here as elsewhere.
Although pastoral counseling and faith~based therapeutic procedures are still widely practiced in North America, and indeed globally, secular, science-based approaches to treating mental disorders have become normative. As psychotherapy has gained recognition as a health discipline, a growing chorus of voices (of both patients and mental health services professionals) has clamorecl for insurance programs to reimburse mental health costs. The establishment of managed health care (MHC) is a business issue and perhaps of little interest to students who Wish to commit their careers to helping people, but the reality is that students will need to ensure that they can run a solvent enterprise after they graduate, even if it is a humble independent practice. Like it or not, therapists
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are quickly drawn into a Web of institutional requirements that will secure not only the safety of the public they serve but their own livelihood as well.
The industrialization of all health professions, whether it be counseling, social Work, psychiatry, clinical psychology, neuropsychology, school psychology, or psychometrics has “been the linchpin of the development and use of empirically based clinical practice guidelines” (Hayes, 1998, p. 27). Readers may recoil from these institutional realities, but they are well advised to generate their personal therapeutic models during their studies and training such that they meet the demands of the accreditation, licensure, insurance, and medical organizations that will facilitate the growth and solvency of their practice.
Epilogue to This Chapter
In the previous edition of this book, Ray Corsini (2008) wrote,
I believe that if one is to go into the fields of counseling and psychotherapy, then the best theory and methodology to use must be one’s own. The reader will not be either successful or happy using :1 method not suited to her or his own personality. Truly successful therapists adopt or develop a theory and methodology congruent with their own personality . . . In reading these accounts, in addition to attempting to determine which school of psychotherapy seems most sensible, the reader should also attempt to find one that fits his or her philosophy of life, one whose theoretical underpinnings seem most valid, and one with 21 method of operation that appears most appealing in use. (p. 13)
A final value of this book lies in the greater self-unclerstanoling that may be gained by close reading. This book about psychotberapies may be psychotberapeutic for the reader. Close reading vertically (chapter by chapter) and then horizontally (section by section) may well lead to personal growth as well as to better understanding of current psychotherapies.
These counsels from a great therapist and scholar are a fitting conclusion to this chapter.
Valedictory
Some readers of previous editions of this book will note that this is the first time that Ray Corsini has not boon the sole author of this introductory chapter. Ray died November 8, 2008, in Honolulu at the age of 94. He left those of us who survive him hcrcft of one of the most creative, loyal, challenging, and inspiring colleagues We’ve had the privilege of knowing and Working with. Danny Wedding, Ray’s co-editor of Psyc/vat/verapzes, and all those, including me, who have had the privilege of working with Ray over the years, bid him a fond farewell and Wish him Well in this journey.
