the compleat therapist

8/18/2019 The Compleat Therapist

1/234


2/234

TheCompleat Therapist


3/234

The

Therapist

J e f f r e y A. K o t t l e r

ompleat


4/234

Copyright © 2013 International Psychotherapy Institute (1991

Jeffrey Kottler)

All Rights Reserved

This e-book contains material protected under International andFederal Copyright Laws and Treaties. This e-book is intended forpersonal use only. Any unauthorized reprint or use of this material

is prohibited. No part of this book may be used in any commercialmanner without express permission of the author. Scholarly use ofquotations must have proper attribution to the published work.This work may not be deconstructed, reverse engineered orreproduced in any other format.

Created in the United States of America

For information regarding this book, contact the publisher:

International Psychotherapy Institute E-Books301-215-73776612 Kennedy DriveChevy Chase, MD 20815-6504www.freepsychotherapybooks.org

[email protected]


5/234

Contents

Preface

The Author

1. How The rap is ts Can Do Such Differen t Th ings

and Still Get Similar Results

2. The S trugg le to Find Th ings The rap is ts Can

Agree On

3. E x am i nin g the V aria ble s T h a t Are C o m m o n to

Most Therapies

4. W hat the Best Therap is ts Are Like as People

5. How Therap is ts Pe rceive, Th ink , Sense , and

Process Their Experiences

6. W hat Therap ist s Actually Do with Clien ts Tha t

Makes a Difference

7. How the Joys and Cha llenges o f The rapeu tic

Work Translate into Effective Therapy

ix

xi

xvii

1

24

43

70

99

134

175


6/234

References

Index

195

211


7/234

Preface

I have a confession. I have been prac ticing, teaching, and w rit

ing abo ut p sych othe rapy for ove r fifteen years and I still do not

know how and why it really works. Do not misunderstand me:

I know what to say about therapy to clients and students, whowould be very upset if they thought I could not explain what

I was doing. I say therapy is a mysterious process. I tell them

it works differently for each person. I explain that it is based

on a tru sting relationship in which we explore yo ur life in depth

and help you to come to term s w ith un resolved issues and make

some decisions regarding where you are headed. We create a

plan to get you what you w ant.

Most people seem to accept that explanation. And I breathea sigh of relief. It took one be lligere nt client to force this con

fession out of me.

“Sir, with all due respect, if that is why therapy works, how

come the previous therapist I saw told me it was because my

family structure needed to be realigned, anothe r I consulted said

it empow ers m e —w hatever that m eans —and still ano ther m en

tioned something about retraining my cognitive patterns?”

Good question, huh? It so happens that I have been askingmyself tha t very question all these years. I started o ut in my

pro fessional life as an avid F reudian. I loved th e com plexity of

psychoanalysis , its poetry, and its regim ented system. I felt safe

X I


8/234

x ii Preface

in the company of peers who all spoke the same language and

helped one another stay on track. I felt it worked well, too; it

seemed to help people gain a clearer perspective on their lives.One influential supervisor urged me to explore more fully

the simplicity of client-centered counseling when Carl Rogers

was the rage. To my utter am azem ent, I found that dealing with

client feelings was indeed a powerful way to work! I aba nd on ed

Freud (or at least swore off theoretical monogamy) during the

“touchie-feelie” days of encounter groups.

A nother me ntor introduced m e to behavior therapy an d the

value of helping clients set realistic goals. If I had reduced attention to the unconscious, defenses, transference, repressed feel

ings, I could be forgiven —my clients m ad e definable p rogress

in leaps and bounds! A lthough I no longer dealt very much w ith

past conflicts, or even present feelings, m y clients im proved by

focusing on specific behaviors they wished to change.

In my doctoral program, I took an advanced practicum in

rational-emotive therapy. This was a time when Albert Ellis,

Aa ron Beck, and other cognitive-based theorists were m akingtheir mark. I eventually became a full-fledged disciple. I read

all the books, went to workshops religiously, an d practiced R E T

exclusively for over a year. I seemed to thrive on the provoca

tive con fron tationa l style o f co un terin g irratio na l beliefs — and

so did my clients. I even tually let go of ration al-em otiv e th er

apy. Although it worked with my clients, I felt so constricted

repeating the same injunctions and interventions over an d over.

When Ericksonian hypnosis, strategic therapy, and neurolinguistic programming hit the professional scene, they were a

breath of fresh air . How could I have been so negligent all these

years in dealing only with individual issues and ignoring fam

ily dynam ics and linguistic structures? I attem pted to rectify my

lapses by mastering these new helping strategies and, again to

my delight, discovered they worked like magic.

W as it because I longed for m ore intimacy in my work, m ore

depth to my sessions, that I came full circle back to an insight-oriented , existential style? O r was it because once I entere d p ri

vate practice, I needed the security of long-term clients? In either

case, I had retained a bit of each of the app roach es I ha d, at


9/234

Preface x iii

one tim e, prac ticed. I was now m ore flexible and ha d m ore op

tions. My clients seemed to improve, maybe even more than

befo re , bu t I believe that was m ore a function of m y experiencethan of which theory I was practicing.

I do not wish to sound cavalier or flippant in m y everchan g-

ing search for the optimal therapeutic approach. Because I have

intensively studied and enthusiastically practiced a number of

different therapies, I feel motivated to take a step back from

parochia l ideology to find the in la id patterns hidden from view.

Fo r I am still perplex ed by how it is possible that these theories

(and a dozen others), which advocate doing such dramaticallydifferent things, could all be helpful. How does therapy work

if it can be practiced by com peten t professionals in such d iverse

ways?

Contents of the Book

Th is is a book abo ut w hat works in psyc hotherapy . I presen t

a synthesis of the best features in most systems of practice anda unified p ortrait of the consum m ate p ractitioner that transcends

theoretical allegiances. It is an attempt to find the essence of

what makes a therapist, any therapist, most effective.

T his book is the third installmen t of a trilogy th at be gan with

On Being a Therapist, an ex plora tion o f how clinicians are affected

by their work with clients; continues with The Imperfect Therapist,

a study of how clinicians handle feelings of failure; and ends

with the present p ublication, which exam ines what consistentlyworks for successful practitioners.

W hereas the previous two books in this series have dealt with

m any of the stresses and challenges that are so m uch a pa rt of

therapeutic w ork, The Compleat Therapist carries a m ore insp ira

tional message: tha t it is possible to synthesize wh at con stitutes

“good” therapy and identify the characteristics, qualities, and

skills that are most likely to lead to positive outcomes.

From que stionnaires, in-depth interviews with practitione rs,a comprehensive review of the literature , as well as my own p er

sonal experience, I have attem pted to answer several im portan t

questions. What makes a therapist most effective? How can it


10/234

x iv Preface

be possible that practitioners who seem to be doin g such diffe r

en t things are all helpful? W ha t do m ost successful clinicians

have in common in terms of their thinking processes, personalqualities, and skills? W hat m ore can we do to pool o ur kno w l

edge and experience to create a new age of coop eration a nd syn

thesis in the practice of psychotherapy?

The first section of The Compleat Therapist contains three chap

ters that explore in depth the commonalities of most therapeutic

approaches. C ha pter O ne describes one of the most perplexing

paradoxes of our pro fession: how therapists can do dis tinctly

different things in their work and yet still prod uce similar results.T he first chapter introduces the m ajor topics of the book, includ

ing the shared themes that are p art of any therape utic encou nter.

Chapter Two reviews the historical as well as current efforts

in the field to integrate diverse therapeutic approaches into a

unified mod el. T his perspective helps us to app reciate ju st how

da un ting is the task of trying to reconcile discrepa nt an d co n

tradictory va riables with a synthesis of w hat we know a nd u n

derstan d, especially when we can not even reach a consensus onlanguage an d concepts. C ha pter T hree operationalizes the work

of eclectic/pragmatic/integrative theorists and practitioners by

reviewing the variables that are common to all effective psy

chotherapies.

The second section of the book examines more specifically

the attributes that are pa rt of a thera pist’s optim al functioning.

Regardless o f espoused theo retical allegiances, professional dis

ciplines, o r style of op era tion , effective the rap ists share ce rtain

qualities (Ch ap ter Four), think ing processes (C ha pte r Five), and

skills (Chapter Six). These identifiable behaviors and processes

tha t are par t of any effective the rap ist’s rep erto ire, regardless

of how they are labeled b y various schools, h elp explain why

so many fine clinicians can appear to be doing such different

things and yet still help clients to change and grow.

The concluding chapter develops the reader’s ability to per

sonalize the many ideas contained in this book so that he or

she can maintain the challenges and joys of effective practice.

The compleat therapist, from the archaic version of complete, con

noting the highest level of attainment in any field, is the ulti

mate goal to which we all aspire.


11/234

Preface xv

Acknowledgments

My thanks to the following therapists who consented to be interviewed, or who shared their views on what being effective

m eans to them: N orbert Birnbaum , D iane Blau, Ro bert Brown,

Brian Con nolley, G erald C orey, K aren Eversole, M arya nn

G reenstone, M aryalice M arshall , Peter M artin, C lark M ous-

takas, Edward Nol, Heather Pietryka, Natalie Rice, Kathleen

Ritter , Deborah Snyder, Lora Valataro, Will iam Van Hoose,

O rlando Villegas, Jo hn V riend, Diane W ebb, and Gail Williams.

I also wish to express my gratitude to the following individuals who reviewed the manuscript and provided many helpful

suggestions regarding its structure and content: Barry Farber,

Will iam Henry, John Norcross, and Constance Shapiro.

I dedicate this book to the two most supportive people I know:

my wife, Ellen Kottler, and my editor, Gracia A. Alkema, who

embody the qualities I most admire in any compleat therapist

or human being.

Charleston, South Carolina

December 1990

Jeffrey A. Kottler


12/234

The Author

Jeffrey A. Kottler is professor of counseling and educationalpsychology at the University of Nevada, Las Vegas. He hasworked as a therapist in a variety of settings including

hospitals, mental health centers, schools, clinics, universities,corporations, and private practice. He has lectured extensivelythroughout North and South America and served as aFulbright Scholar in Peru establishing counseling programs inunderdeveloped regions.

Kottler is the author or coauthor of Ethical and LegalIssues in Counseling and Psychotherapy (1977), PragmaticGroup Leadership (1983), Introduction to TherapeuticCounseling (1985), On Being a Therapist (1986), TheImperfect Therapist: Learning from Failure in TherapeuticPractice (1989), and Private Moments, Secret Selves: En-riching Our Time Alone (1990). He is currently an associateprofessor of counseling at The Citadel in Charleston, SouthCarolina.

xvi i


13/234

TheCompleat Therapist


14/234


15/234

C h a p t e r O n e

How Therapists Can Do

Such Different Things

and Still Get Similar Results

W h y are some therapists generally helpful and some are not?

Jo u rn als an d books are full of plausible exp lanations, rang ing

from the frequency of using certain interventions to the pres

ence of particular interpersonal factors. And yet, while theoreticians, researchers, and practitioners argue among themselves

abo ut w hat exactly m akes a difference —which elem ents, va ri

ables, qualities, processes, concep ts, behav iors, and a ttitudes —

clients are remarkably clear about what they want and need in

their helpers. G enerally, they prefer someone who is w arm and

approachable, someone who listens to and understands them.

Th ey w ant a professional who is com petent an d confident, who

gives them a sense of hope. They want an active collaboratorin the process. Th ey w ant som eone who they perceive to be like

themselves, but not too similar. T he y favor a helper who is also

emotionally healthy. A nd they prefer an expert who is perceived

as having power, status, and prestige. In short, clients have

definite ideas abou t wh at they w ant in the ir helpers, even if they

do not know what they want in their lives.

A Client Looks at Three Therapists

D urin g the w riting of this book I exp erienced w hat I believe

was a mid-life transition. I began to feel restless with my life,

1


16/234

2 The Compleat Therapist

confused as to what I wanted to do next, and somewhat un

happy with the progress I was making on my own. I was feel

ing anxious, and then once I beg an ex ploring options, I startedfeeling depressed by what I perceived were limited possibilities.

W hat I was living throug h had all the hallm arks of w hat I recog

nized as a developmental crisis.

I became indecisive. I found it difficult to concentrate. And

yet, I suppose like most prospective consumers of therapy, I

made up a bunch of excuses for why I could handle this on my

own. I am a therapist, after all . . . and a pretty good one. I

should be able to help myself through this, just as I have livedthrough it with so many clients. Finally, I rationalized to my

self tha t this would m ake good resea rch for the book I was w rit

ing. (W ha t is the use of being a the rap ist if it does not help us

to invent good rationalizations?) All in the interest of science,

I could visit several different therapists and see what m akes them

effective, actually experience the effects of what they do. Hey,

maybe I would even find it personally helpful.

I scheduled appointments with three different therapists inthe same week, unw illing to trus t ju st on e. I figured I could see

what each of them was like and decide who was the best for me.

M y first awareness after taking this initial step was already how

m uch be tter I felt. C lients, of course, have said this to me all

the time, bu t I had n ot realized ju st wh at they me an t. (It has

been m any years since my last therapy experience as a client.)

I noticed myself doing a lot of rehe arsing o f how I w ould present

m yself an d what I would say. It was ha rd to sit back , relax,wait, and trust the process I purport to believe in and teach to

others. It was a test of faith.

Dr. Genghis. T he first therap ist was a small m an in a cav ern ous office. T rain ed originally as a psychiatrist an d analyst, D r.

Genghis’s office had many of the trappings I would expect in

such a setting —big desk, swoon couch, sepa rate entrances. Very

formal. Yet I did not for a moment expect I would be seeinga conventiona l ana lyst . . . an d I was no t disappoin ted.

Before I even got my bearings and settled in my chair, he

was on me like a predator. He asked me some questions but


17/234

H ow Therapists Can D o D ifferent T hings 3

did not like my answers. It took him about five minutes to size

me up and give me his assessment. And it was brutal. I reeled

from the accusation that I was essentially irresponsible. I triedto process what he was saying, bu t by then he had leveled several

m ore round s. M y back was dren che d with sweat. I was smiling

like an idiot, stam m ering out my protests of disagreem ent.

“It’s sim ple ,” he says. “You d on’t w an t to grow u p .”

“Well, that could be true, but . . .

“See, even now you intellectualize. You talk around things.

You do n’t say what you m ea n.”

Gosh, he was right ab ou t that. M ayb e the other stuff is true,too. And if so, then everything I thought about myself is false.

I am not who I am, but someone else I do not know.

I could see where he was taking me and I did not like it one

bit. If I stayed in treatm en t w ith him I would become m ore

responsible, more like him, and what he views is appropriate

conduct for a ma n m y age. Sham e on me for w anting to change

aspects of m y life tha t were not b rok en —all to placate some silly

dream I will never reach.“K ottler, when are you going to stop this nonsense, stop ru n

ning away, and start facing yourself?”

I was devastated. My knees felt like rubber; I could barely

walk. I sat in my car for an hour trying to recover from the

onslaught. In some ways he really had me pegged. But could

it all be true?

Clearly, I was genuinely m oved by this experience. I cann ot

recall, ever, spending a more frightening hour in my life. I felt beat up , bruis ed, and yet it was a “good” ache. I was even te ll

ing myself: “Boy, th at was fun !” like a kid who sc ream ed in te r

ror all the way thro ugh a roller coaster ride, stumbles off in tears,

and then says, “Let’s do that again!”

T he q uestion was, should I go back? A pa rt of me was so

intrigued by his bluntness and assaults on what I thought was

my reality. A nd ano ther p art of me tho ugh t he was a lunatic.

He was everything I have always wanted not to be as a therapist. He was neither warm nor accepting; in fact he was ex

tremely critical and judgmental. He did not deal with my feel

ings nor did he work with me in areas that I preferred. He


18/234


19/234

How Therapists Can Do Different Things 5

was especially revealing of my un derlying skepticism and m is

trust of the process that I have devoted my life to believing

in . . . for others.In spite of my app rehension s, by this time I really needed pro

fessional help ju st to recover from the first experience. D r. G linda

was as different from Dr. Genghis as two therapists could be.

Eve rything he was no t, she was. A nd vice versa. She was w arm ,

approachable, quite loving and caring. I felt unnerved by her

look. It was as if she knew some deep , d ark secrets abou t m e

too, but unlike Dr. Genghis, she was not going to share them yet.

W e spent m ost of the session talking abou t the m ean ing ofthe previous session with Gengh is. She asked me how I felt about

changing my basic nature: “How does it feel to have an expert

tell you that you don’t know what’s good for yourself?”

D r. G linda did everything I w ould have don e for myself if

I had walked into my office as a client. She listened closely. She

supp orted m e. She reinforced the idea tha t I did know w hat was

best. W ell , th is was ju s t w hat I w anted to hear. M aybe I would

not have to grow up after all!I found D r. G lind a to be effective in most senses of w hat I

would expect from a therapist. She heard me and understood

what I wanted from her at that moment (although she may have

been colluding with m y resistance). It certainly was not nearly

as frightening to work with her. I felt safe in her presence. She

seemed to genuinely care about me. She would go at my pace

rather than hers. I decided this was also someone who could

help me, but in a way profoundly different from Dr. Genghis.

Dr. Wright. The first thing that struck me about the thirdtherap ist I consulted was his smile —he seem ed so natu ral and

inviting. D r. W right appe ared to be the perfect com prom ise be

tween someone who is caring yet confrontational, low key but

direct. He gave me hope but made no promises. I knew after

five minutes that I had found an excellent match.

Once I had decided in my own mind that this was the professional I could trust and who I believed could help me, I tried

to figure out what about him seemed most significant. I liked

his calmness. He listened very closely, and proved it by de

scribing things I said in a way I had never considered before.


20/234


He asked me difficult questions that I could not answer. I liked

that.

I think, above all else, I had an im age in m y m ind o f whocould help m e —and D r. W righ t fit the profile I was looking for.

I enjoyed the m essages I he ard from him —tha t he w ould let

me do whatever I wanted and be whoever I am. I realized also

that it was not only im po rtant to be hea rd, bu t to be responded

to.

It was frustrating to me that I could not put my finger on

exactly what m ade this therapist right for me. H e was not us

ing any interventions or techniques that w ere not pa rt of therepertoire of others. H is app roach also seemed to be som ewhat

sim ilar to what I experienced before —an insigh t-oriented style

that was part psychodynamic, part existential, and yet some

what pragmatic. Yet, as hard as I could try, I could not (and

cannot) put into words what D r. W right did that I found so help

ful. Perhaps that was because it did not matter what he did as

m uch as how he was with me. H e seemed self-assured bu t quite

modest and low key. He was intense but also relaxed. He wasobviously quite bright but did not feel the need to prove any

thing. In short, Dr. Wright was what I wanted to be.

W hat was app aren t to me was that he was a desirable model

for me —in fact, he was the “m e” I show to clients, altho ug h I

rarely get a chance to observe that person. H e was intriguin g to

me as a human being, someone I looked forward to spending

time w ith. Y et as good as it felt to be w ith D r. W righ t, I still

walked ou t of his office confused. For wh ichev er the rap ist Istayed with, I felt that I w ould miss out on w hat the others could

offer me —w hether it was D r. G eng his’s bo ne -jarrin g co nfro n

tations or Dr. G linda’s soothing nurtu ran ce. Each of the three

touched a pa rt of me that was responsive to what they were do

ing and being. And yet I felt comforted with the realization that

I really could not m ake a m istake: any o f the three could help

me grow; it was ju st a question o f which roa d I wished to take.

Understanding Our Common Language

In the ir research on how experienced therap ists select their own

helpers, Norcross, Strausser, and Faltus (1988) found that de


21/234


cisions were made primarily on the basis of professional com

pete nce, experie nce, and repu tatio n , as well as personal quali

ties such as w arm th, flexibility, an d ca ring. Ind ee d, like the 500therapists in their study, I did n ot particularly care ab ou t which

theoretical orientation my therapist followed, as long as he or

she was an expert at applying it and had the capacity to treat

me with kindness, compassion, and respect.

Also evident in my experiences in search of a therapist are

the m ajor themes explored in this book: (1) there are m any differ

ent ways to be helpful to peop le, (2) there are som e things that

all effective the rap ists do, an d (3) it is possible to iden tify c om m on therap eutic principles and integrate them into a personally

evolved style of practice.

What makes this task of searching for common denomina

tors among diverse theoretical systems so difficult is the exis

tence of so man y distinct languages tha t are spoken a m on g tribal

groups: “If the phenomenologist uses terms like ‘the phenom enal

sense of self,’ the psychoanalyst, ‘projection of m en tal re pre sen

tation s onto o the rs,’ and the be hav iorist, ‘con ditioned stimu liand responses,’ how are we to un de rstand each other and de

velop a common framework?” (Messer, 1986, p. 385).

W e have trouble com m unicat ing with one a nothe r when we

speak different langu ages an d com e from d ifferent professions,

training p rogram s, p hilosophical positions, theoretical orienta

tions, and work settings. And we have little tolerance for col

leagues who operate differently tha n we do. W ha t is truly am az

ing is that therapists who operate as differently as the three Iconsu lted could all be effective with the ir clients. T he inesca pa

ble conclusion is that we m ust have m ore in com m on with one

another than we are willing to admit, including the definition

of w hat constitutes a successful reso lution o f the c lient’s prese nt

ing complaints.

Definitions of Effectiveness

W ha t does it mean for a therapist to be effective? Certa inly it

is more than “having an effect,” as the word implies, since effec

tiveness is jud ge d principally on the basis of meeting stated goals.

In the case of psychotherapy, we are also concerned with


22/234

8 T he Com pleat Therapist

the kind of effect we initiate, since ou r influence can be for bet

ter or worse. Ineffective therap ists m ay, in fact, p rodu ce m ore

of an effect than those who are most helpful.If positive outcomes are the criteria by which effectiveness

is judg ed , then w ho determines w hether the results are positive,

and how is this decision made? If it is the therapist, as expert,

who makes this determination when he or she has performed

well, then the evaluation is subject to all of the biases and per

ceptual distortions that are part of any subjective assessment:

“T he client seems better to m e, so I guess I’ve done good w ork .”

O f course, we are actually a lot m ore obtuse th an that. W ewill state essentially the same thing in progress notes, but cloaked

in pseudoscientific jargon to lend credibility to our optimistic

opinions: “There is a significant reduction in the frequency of

depressive sym ptom ology .” T his e valua tion is usually based on

two considerations: first, the observations of the client during

interviews, which m ay o r ma y n ot reflect actual func tioning in

the outside world; an d second, the client’s self-report abou t how

much he or she has improved.Ultimately, then, by direct or indirect means, the client de

cides the degree to which he or she has been helped. This is

true for most other professions as well —it is the physician’s pa

tient, the attorney’s client, the salesperson’s customer who de

term ines the degree to which the p rofessional has been effective

in getting the job done. T he effective therapist, there fore, is a

professional who pro duces a hig h num ber of “satisfied cus

tomers.”But this cann ot be the whole picture. T he re are prac titione rs

who, because of the way they work, are successful in the ir clients’

eyes, but not necessarily in meeting initial treatment goals. They

may be effective, essentially, in fostering dependencies in their

therapeutic relationships, or creating distortions or denial of u n

resolved issues. One common way this takes place is in the as

sertion that: “You are better, you just don’t know it yet.”

Just as multiple measures of therapy outcomes (client self-report, observer ratings, changes in dependent variables) are

used simultaneously in research settings, the clinician relies on

several criteria to measure progress. While the most important


23/234


is the client’s assessment of “feeling better,” we also collect data

from family members, clinical observations, and a “felt sense”

that things have improved. The compleat therapist is skilled notonly in producing consistent positive outcomes, but in assess

ing all changes accurately and honestly.

Statistically Insignificant but Clinically Meaningful

Research efforts during the past three decades have been de

voted to figuring out the complex puzzle of which core conditions

of helping seem to be related to positive outcom es. D ep en dingon which dependent variable is measured (client perception or

observer ratings or frequency o f behaviors), it can be found that

variables such as empathy, warmth, and genuineness are im

portant, are not im portan t, o r are som etim es im portant (O r-

linsky and Howard, 1986). Based on empirical research, perhaps

all we can conclude is that em pathy m ay or m ay no t help, but

it does not seem to hurt.

Allen Bergin, coeditor of the classic research volume H and-

book of Psychotherapy and Behavior Change (1986), lam ents his own

frustration with trying to reconcile hu nd reds of discrepant studies

and somehow integ rate them into clinical practice. In an earlier

work on the synthesis of therapeu tic theory and research, Ber

gin (1980, p. 85) advises us to trust our intuition and personal

ju dgm ent as well as the findings of em pir ical research: “T he field

of psychotherapy is m ade up of ma ny different kinds o f views

and findings. With some we may have a fair degree of confidence, with some we may feel the data point us in one direc

tion, bu t ju st slightly, and in others we may ha ve to conclude

that in the absence of da ta we are proceeding on w hat ap pea r

to be reasonable or warranted hypotheses or assumptions. Fi

nal answers are simply not available, and we must proceed on

what appears to be the soundest path possible. In some instances,

we can have confidence that our procedures are based on rea

sonably sound empirical results. In others, we must trust ourown jud gm en t and intelligence, reco gnizing fully w hat we are

doing and the bases for our decisions.”

We are left with the realization that research to date has not


24/234

1 0 The Compleat Therapist

always suppo rted those variables tha t m ost of us believe con sti

tute effective therapy. There are more than a dozen different

studies that show that even the clinician’s level of experience

is not necessarily a predictor of effectiveness. But, of course,

we know it is, if it is the kind of practice that truly qualifies as

“experien ce” —tha t is, fur the r exposure to new kn ow ledge, sit

uations, opportunities that are processed in a way that fosters

growth. T he othe r kind o f “experience” m easured in these studies

is the kind in which the longer a therapist practices, the more

cynical, lazy, and rigid he or she becomes.

Th is lack of con sistent, em pirical supp ort tha t can be rep li

cated in a variety of situations ov er tim e is w hat m akes the d e

bate s over what works best in our pro fession so in te nse. T here

are studies available to substantiate or refute almost any claim

one would like to make. The behaviorists have convincing evi

dence that psychoanalytic treatm en t is no thing but the hap ha z

ard application of such principles of reinforcem ent and extinc

tion. The analysts can dem onstrate that the behaviorists are only

dealing with surface symptoms and not getting at the root of

problem s. T he cognitive therapists can show dozens of studies

substantiating their claims that all other clinicians are missing

the key to chan ge, as can alm ost any o ther school of thou gh t.

It All Looks the Same to Me

A stranger to our culture would be quite puzzled by what all

the fuss is abou t —this bick ering ab ou t which th erap eu tic a p

proach works best, th e conflicts and argum ents about w hat

makes therapy most effective. After all, to even the most astute

observer, things would seem very much the same in offices across

the land. Look in on a therapist, any therap ist, an d we are likely

to see two people sitting com fortably opp osite one an othe r. Ba

sically, the room would be furnished just like any other of its

kind —frame d pieces of pape r a nd colorful ima ges on the w all,

booksh elves, a desk , a few chairs and a couch, a file cabin et,and a phone. Usually a Kleenex box.

Perhaps this alien visitor would be a little surprised to dis

cover that in a certain pe rcen tage o f these offices tha t also ca ter


25/234

How Therapists Can Do Different Things 1 1

to little people of ou r cultu re, there would also be some toys

on the shelves. Bu t, basically, the office of any the rap ist would

look pretty much the same. And so would the procedures.O u r stranger would probably assume that all practit ione rs

of this profession do the sam e things. H e o r she would no tice,

for instance, that the two participants app ea r to like one an othe r,

since they seem at ease, take turn s talking, an d show caring an d

respect for what the other has to say. In fact, the alien would

be surprised to find that this is the one place he or she has visited

where people seem to truly listen to one another. This is obvi

ous because there are no interruptions or distractions. Everything is quite private and discreet. They even repeat what the

othe r says occasionally, ju st to show they are p ay ing atten tion.

Fu rther, each m em ber of the pa rtnership seems to be m ore im

porta nt than the oth er in different ways. At first, the visitor would

assume it is the one who owns the office who is most

im po rtan t —after all, she occupies the m ost com fortable chair

and seems to be directing things, even when she is silent. But

then, the obse rver would notice that the o ther one —the one whosom etimes cries or displays intense em otiona l reac tions —seems

to be the m ore im po rtan t of the two. H e is the one who chooses

w hat they talk abou t. It is almost as if the o the r one works for

him , the way she comm unicates an attitude of “w hatever you

w an t.” An d strangely, she does this without a pp earing subse r

vient or sacrificing her own power.

From these visits to therapists, the alien would have to con

clude that, while there are some subtle differences in what theydo —some talk a bit mo re o r less, some seem m ore or less p er

missive—there are few substantial deviations (although at one

strange place the alien saw the therapist molding members of

the same family into frozen positions where they looked like

statues pointing or leaning on one another). The one person,

who seems to need help, walks in, introduces himself, and tells

his story. T he oth er one , offering such help, listens very closely,

asks questions, and supports the person to do what he mostwants. Sometimes she offers more direct interventions, explains

things, rem inds him o f previous things tha t were said, even

challenges him to consider other alternatives. But to this innocen t


26/234


alien, not concerned with detail or trained to detect subtlety,

it all looks the same. A person feels lousy. He goes to talk to

this professional about what is bothering him. And he leavesfeeling better.

It is the p rem ise of this book tha t n ot only could an innoc ent

observer be unable to discern significant differences among most

therapists who are effective, but trained experts have their

difficulties as well. W hen we filter ou t the ja rg o n an d the su pe r

ficial concepts, w hat we have left is a consensus of effective pra c

tice. If we do no t get so cau gh t up in which ap proa ch works

best and concentrate in ste ad on w hat univ ersal and specificaspects of each approach work best, what we will have is the

essence of effective therapy.

What’s the Difference?

In 1980, H erink pu blished an encyclopedia of psychotherapy

approaches that con tained m ore than 250 entries. If we con

sider that in the decade since this publication the trend towardthe proliferation o f different therapeutic m odalities has continued,

and if we con sider tha t the editor missed m any oth er theories

that are out there, I am certain that the actual n um be r of con

ceptual frameworks would run into the thousands. Perhaps it

could even be said that for each practitioner of therapy there

is a un ique implicit theo ry of op eration tha t is being applied,

one that reflects the individual personality, values, interests,

goals, trainin g, and experience o f each clinician.Yet all these diverse approaches produce similar results: satis

fied clients. Lu borsky, Singer, an d Lu borsky (1975) cond ucted

a com parative study of all m ajor forms of therap y th en in exis

tence. They calculated “box scores” from each outcome study

and tallied the results, co ncluding that all forms o f therap y

studied have demonstrated effectiveness, and no approach to

therapy w orks better than any o ther. In an up date of this study

completed a decade later, Luborsky an d others (1986) concludedtha t w hatever differences do exist in va rious types of trea tm en t,

they have little to do w ith the the ory th at is applied an d eve ry

thing to do with who the individual therapist is.


27/234


If we assume that all of the hu nd reds of therape utic m etho d

ologies now in existence continue to flourish because they are

helpful with some people som e of the tim e, we are left with theconclusion that: (1) it does not make much difference what ap

proach is used, or (2) all o f the approaches are doing essentially

the same things.

Even thou gh therapists may be doing different things in their

sessions —inte rpr etin g d ream s, role playing, reflecting feelings,

dispu ting irrationa l beliefs, an alyzing them es, reinforcing fully

functioning behaviors, am ong thousands of other possible tech

niq ue s—it is ap pa ren t that most seem to be getting the jo b done.W ha t, then, do effective the rapists have in com m on if not a

shared theoretical base or body of interventions? If we assume

the differences are more illusion than reality, or that they are

tangential rather than truly substantive, then perhaps we are

all doing essentially the same things with our clients.

Similarities and Differences

While the premise of this book is that effective therapists have

mo re in com m on than would seem ap paren t from their espoused

differences, it should also be mentioned that there are several

factors that clearly differentiate helping styles. In a survey of

attempts to measure differences in theoretical orientations, Sund-

land (1977) described several variables acco rding to which the r

apists differ — for exam ple, in te rm s of the ir ac tivity levels (pas

sive versus active), directiveness (g uidin g v ersus challenging),structure (spontaneous versus planned), control (permissive

versus limit-setting), temporal focus (past versus present), na

ture of alliance (au tho ritarian versus egalitarian), d og m a (rigid

versus flexible), and content (cognition versus affect).

Therapists can vary in each of these dimensions and still be

effective. They can work in a highly structured way or a style

that is more intuitive and spontaneous. They can talk a little

or a lot. How ever, in spite of these variances, most effective the rapists have a lot in common. Consider, for example, the be

havior of some of the leaders in our field.

In the second volum e in this series (K ottler and Blau, 1989),


28/234

14 T he C om pleat T herapist

several of the profession’s m ost p rom inen t th erap ists described

their experiences with failure, and by so doing , also articula ted

what they believe does play the most significant role in therapy. T he following com m onalities of wh at works in the rapy can

be constructe d from w hat does not work in the therapy of A r

nold Lazarus, Albert Ellis, Clark Moustakas, Richard Fisch,

James Bugental , and Gerald Corey:

1. understanding, accurately and fully, the nature of the client’s

presenting com pla in ts

2. establishing a productive therapeut ic alliance3. exhibiting confidence in the methods employed

4. dem onstrating flexibility when and where it is needed to

alter plans to fit specific client needs

5. being aware of one’s own limi tations and cou nter transfer

ence reactions that may be impeding progress

6. employing specific interventions with a defensible rat ion

ale that can be articulated

This last area of prescribing specific strategies with different

clients and pre senting com plaints has been seen by m an y, such

as Jo h n Norcross and A rnold Laz arus, as the ha llm ark of effec

tive practice. In a n invited address at an A m erican P sychologi

cal Association co nve ntion, La zaru s (1989) called m an y o f the

conclusions o f m eta-analysts —and of oth er w riters w ho believe

that generalized effects of therapy are what make the greatest

difference —utte r nonsense! Lazarus explains: “T he re a re thosewho hav e said it’s all in the re lationship . If yo u’ve got a good,

w arm , em pathic, loving relation ship, the rest takes care of it

self. And if that’s the case, why the hell bother to collect doc

torates, study, take courses, if being a nice hu m an being is all

that matters?”

Lazarus emphatically states that there are indeed very spe

cific treatm en ts of choice for specific prob lem s —lithium ca r

bonate for bipolar disorders, response preventio n for com pulsive disorders, sensate focus exercises for sexual dysfunctions,

limit-setting for borderline personalities. He believes that all ther

apists, regardless of train ing and professional and theoretical


29/234


affiliations, should be able to agree on the most optimal strate

gies to employ with problems such as these.

In spite of a possible reconciliation of viewpoints regardingsituation specific trea tm en t me thodologies, there is one b one o f

contention between many theoreticians and clinicians: whether

the client or thera pist should assum e p rim ary responsibility for

therapeutic gains. Whereas some practitioners believe that the

client is the one who directs progress and m ove m ent in sessions,

othe r therap ists feel ju st as strongly that the the rapist is the one

in cha rge. W ha t is so intere sting is tha t both strategies seem

to work.I suppose this really is not so extraordinary when we con

sider that unique styles of practice are part of any profession.

Athletes can perform at their peak by strategies that either em

phasize reg im ented, discip lined hard work or a rela xed m an

ner. C onsider the perform ance o f baseball players. Some espe

cially successful hitters are able to attain their level of skill

throu gh endless practice, the scientific study o f relevan t p rinc i

ples, and o ther fo rm s of sin gle -m in ded determ ination . T hese“left-brained” professionals are not unlike those therapists who

are highly effective in their structured styles. Yet other “right-

b rained” hit ters or therapis ts are able to be ju s t as effective by

relying on intuition, a relaxed m an ner, and natural an d trained

reflexes. So what is operable is not which style is used; rather

the common variable is that the practit ioner has developed a

un iqu e style that feels personally com fortable. A nd , of course,

anyone who invents a unique theory is going to be even moreat ease practicing what has been custom designed to his or her

own personality, values, and needs.

Yet, an oth er reason w hy the various forms of thera py are all

effective is not only because they do the same things, but be

cause they do different things. Each system relies on distinct

learning principles. T hese could include mechan isms o f trial and

error, experientially based processes, didactic instruction, model

ing demonstrations, reinforcement principles, gestalt insights,classical conditioning, gradual learning curves, response dis

crimination, intuitive sensings, problem solving, or neu roch em

ical information processing.


30/234

16 T he C om pleat T herapist

Since individua ls have d istinct preferences in terms of how

they learn best, therapies that employ some concepts are going

to be more useful to some people than to others. Those clientswho work well with structure and concrete goals are going to

naturally gravitate towa rd a therap ist who can w ork well within

those param eters. An d others who prefer the realm of the in

tellectual or the experiential will search until they, too, can find

a good m atch. A nd the n, o f course, the re are those who can

adapt quite well to almost any system. Bu t the point is tha t there

are many ways to accomplish the same things.

I am rem inded o f a furious debate th at took place at a hea ring of a state Board of Licensure in which a number of rule

changes for practice had b een prop osed. O ne o f these included

adding a m anda tory residency requirem ent in doctoral programs

that would effectively eliminate many alternative schools that

are geared to older students who cannot leave or relocate their

families to com plete the ir studies. A rep resen tative o f one p res

tigious state university gave an impassioned and quite articu

late speech abo ut the necessity of co ntinuo us, ong oing su pe rvision and classroom monitoring in the training of a therapist .

He believed that such daily contact with peers and instructors

is critically im po rtan t in the deve lopm ent o f good w ork habits.

In fact, he could not conceive of training a therapist any other

way, and found it absurd that someone could ever be licensed

as a professional who had not spent prolonged time in residence

at an institution.

A representative from one of the nonresidency program s then presente d an equally com pell in g argum ent: “I understand th at

you learn best in a formal classroom setting, and perhaps even

the students that you have worked with do well in lecture halls

and seminar rooms. I , however, have much preferred concen

trated periods of interaction with my peers and instructors, with

tim e in between these meetings to study, read, an d practice in

dep end ently. So what you are saying is tha t studen ts who learn

differently than you do can’t possibly learn to be competent therapists.”

There have been endless arguments among the representa

tives of the various schools of thought as to which approach is


31/234


the best. Both sides level this claim: “You are patently incor

rect, w hereas we have the m arket on truth cornered. If only

you w ould do wha t we do so well, then yo ur clients would makemore real/rapid/lasting changes.”

Several things are clear: (1) different therap ists do apparently

different things, and (2) except for adopting certain behaviors

that are kno wn to have d eleterious effects, no m atte r wha t they

do, their clients get be tter anyw ay. W he the r the clinician is fond

of listening or talking, sup po rting or con fronting, reflecting or

advising, clients will typically resp ond favorab ly if certain basic

conditions are met. Empirical research cannot yet account forthe paradoxical finding that therapists who do different things

get similar results, so that there is something else going on that

we cannot altogether explain.

Shared Them es in the C lient’s Jou rney

T here is doub t in some circles as to wh ether any thing the th er

apist does makes m uch of a difference in p roducin g positive ou tcomes; rather, it is the client who is effective or ineffective, not

the clinician. This nihilistic perspective was expressed by one

psychiatris t who claim ed to have strong reserv ations with regard

to any therap ist or therapy as bein g effective: “In m y experience

the person ‘un de rgo ing ’ the rap y is the one w ho is doing the ‘get

ting b etter’ an d hence he is the one being effective. I know tha t

many clients object to accepting the credit for their improve

ment and they will insist that the therapy has made them better. I can no t blam e them . It is exp ensive stuff. A lso, if you re

fuse responsibility for yo ur im prov em ent you can always blame

others or extern al circum stances if things do no t go right in the

future.”

T he perspective revealed by this clinician —that therap ists are

ne ithe r effective n or ineffective, it is the ir clients w ho are —is

somewhat provocative. Yet, it is a shared theme in all thera

pies that th e client is th e one who does th e changing based onhis or her motivation.

Stiles, Shapiro, and Elliott (1986) contend that “there really

are different ingredients in the different psychotherapies, although


32/234

18 The C om pleat Therapist

whether these are active ingredien ts or flavors an d fillers remains

to be established” (p. 166). The authors attempt to resolve the

paradox by poin ting out m eth odolo gic al proble m s inherent incom parative studies of outcom e. W hile they m ention tha t in

deed com m on features shared by all therap ists (such as warm th

and com m unication o f new perspectives) or therapies (such as

the therapeutic relationship) might override differences in ver

bal te chniq ue, they also pro pose that perhaps it is not th e th e r

apist’s behavior that matters much. Maybe it is the client who

makes all the difference. Those who have positive and realistic

expectations, who are trusting and disclosing, who have acute pro blems, no severe personality dis tu rbances, and who are will

ing to accept responsibility for their growth, are going to do

well in practically any form of therapy with almost any pract i

tioner.

Even if this were so, effective p rac titioners a re those who can

nurture the right qualities in their clients. Even those clients

who are poor risks because they have neg ative, unrealistic expec

tations, chronic problem s, an d av oida nt styles can be helped tochange them. It is jus t in the way this is done —throug h pushing ,

shoving, wa iting, or g uiding —that me thodologies are different.

To return to the baseball m etapho r: ninety pe rcent of all

professional players can hit a little white ball traveling at 90 miles

per hour to a place where nobody else is standing betw een 25

and 30 percent of the time. T o the un trained eye, they all ap

pear to be doin g the same th ing: sta ndin g th ere sw inging a stick.

But to anyo ne who has studied this activity, there a re vast differences in technique that are equally effective. One can hit from

the left side, the right side, or both, and yet that makes little

difference. People have different stances, grips, rituals, train

ing rou tines, philosophies, an d strategies —and they all work

if certain basics are followed (lightning reflexes, upper body

strength, adaptability, and so on).

All of these things could be said about compleat therapists.

O n the surface, it does appe ar as if we are doing different things.Yet a new stud ent of ou r discipline w ould have as m uch trou

ble seeing these differences as would a fir st- tim e spectato r at a

baseball game: we all look like we are s tanding up th ere with

a stick swinging away.


33/234

H ow Therapists Can Do D ifferent Things 19

There are those who doubt that it is possible to find a com

m on factor across all the rapy. Yet it could be said that the stru g

gle of all human lives comes down to a single story told againand again in our mythology. In his classic work on prevalent

themes in folklore, C am pbe ll (1968) traces the com m on threa ds

found in various cultures since ancient times. These myths are

constructed not as a pure art form, or as history or entertain

ment, but they all tell the same story. He sums up (1968, p.

3) that “w hether we listen with aloof am usem ent to the dre am

like m um bo jum bo of some red-eyed witch do ctor of the Congo ,

or read with cultivated rapture thin translations from the sonnets of the mystic Lao-tse; now and again crack the hard n u t

shell of an argu m ent of A qu inas, or catch sudden ly the shining

meaning of a bizarre Eskimo fairy tale: it will be always the

one, shape-shifting yet marvelously constant story that we find,

together with a challengingly persistent suggestion of more re

maining to be experienced that will ever be known or told.”

No m atter w heth er disguised as Apollo, B uddha, O edipus,

or the Frog King, the legends and myths across time have followed similar rites of passage: the hero stumbles on a magical

world tha t contains great obstacles to be overcome. Th ese stru g

gles lead to the c rossing o f a thresho ld a nd the reso lution o f life’s

riddles.

Th is jou rne y th at is so prevalent in the m yths and legends

of all cultures is also a vivid desc ription of w hat the client ex

periences while undertak ing alm ost any th erapeutic jou rney .

Campbell identified the following stages:

Call to Adventure. By some surreptit ious event or blunder,

a chance enc ou nter opens a window to a new, m agical, om inous

world.

R e fu sa l o f the C all . There is balking and reluctance to ac

cept the invitation; fear and a pprehe nsion scream out w arnings.

Superna tura l A id . For those who venture forward, the first

enco un ter is with a guiding figure (fairy godm other, angel, help

ful crone, Merlin, Hermes) who gives advice and amulets as

prote ction against th e forces of evil.


34/234


Crossing the Threshold. T he hero en ters the w orld of theunkn ow n, the darkness of un certainty. H e or she steps beyond

the portals of secure grou nd onto m ore precarious footing — one that holds a p romise of rewards, but also of dan ger.

The Trials. For a while things look pretty bleak. The herois stymied and frustrated by the obstacles that seem insurmount

able; however, with perseverance and a tireless will, he or she

confronts a series of tests. T he hero is supp orted by a be nign

power th at cannot be seen. H e or she su rv ives the ord eals , wiser,

stronger, carrying the spoils of victory.

Refusal to Return. With the mission accomplished the herois reluctant to leave the magic kingdom and the benevolent p ro

tector. Yet the hero is commissioned to return to the outside

world to give back what he or she has taken or learned.

Rescue from Without. The return is not without dangers ofits own. Often assistance is required from someone on the outside —either a loved one w ho is waiting or the prospec t of a new

relationship.

Master of Both Worlds. Th e hero a ttains the status of M asterafter being able to travel between the mag ical land a nd the world

he or she now resides in —w ithou t letting o ne c on tam inate the

other. “Even as a person casts off w orn -ou t clothes an d puts on

others that are new, so the embodied Self casts off worn-ou t bo dies an d en ters into others that a re new. W eap on s cut It not; fire

burns It not; w ater wets It not; th e w in d does not w ith er It. This

Self cann ot be cut nor bu rnt n or wetted no r withered. Eternal,

all-pervading , un ch an ging , im m ov able, the Self is the same

forever” (Bhagavad Gita, quoted in Campbell, 1968, pp. 22-24).

If this jou rn ey sounds suspiciously fam iliar, it is because, ac

cording to Campbell, the usual initiation rites and transitional

rituals have been replaced in ou r culture by the jou rne y of psychotherapy. This is illustrated in the following example. Brenda

en ters the office after a crisis has pre cipita ted panic attack s —

she discovered her husband is having an affair (Call to Adven-

ture). At first, she was reluctant to confront the issue; maybe


35/234

How Therapists Can Do Different Things 2 1

if she left it well eno ug h alone, the re lationship wo uld en d on

its own (Refusal o f the Call). But her symptoms only becam e worse,

disrupting her sleep, her appetite, and the ways she related toher husband.

W ith con siderable help from h er therap ist (Supernatural Aid),

Brend a begins to explore not only the dy nam ics of he r m arriage,

but also th e circum stances that perm itted her to feel so vulner

able an d helpless in o ther areas o f he r life (Crossing the Threshold).

She attem pts to confront her husb and , w ho denies any indiscre

tion, claiming it is all the result of he r overactive im ag ination .

Unwilling to live any longer with a relationship she now realizes has been em pty and destructive for quite some time, Brenda

decides to move out on her own (The Trials). M uch to her sur

prise, although she still feels generally anxious, th e orig inal de

b ilita ting sym pto m s of panic have now subsid ed. She feels re

solved to continue her efforts at growing.

Yet Bren da has come to depen d on h er therapist for supp ort

and guidance (Refusal to Return). How can she ever m anage be

ing really and truly alone? T hey begin to work on helping herto internalize what she has learned and to wean herself from

this transitiona l dep end enc y. She starts socializing with friends

more often and even starts to date cautiously (Rescuefrom With-

out). She experim ents m ore and m ore with her sense of pow er

and self-control. This increased confidence is most evident in

her b eha vior in the singles grou p she has joine d: she takes a

more active role in helping others beginning the struggles that

she is now completing (Master of Both Worlds).

T he shared them es of m ythological tales and the psycho ther

apy process highlight the universal variables that have been part

of adv entures in growth for thou sands of years. W hile all com

pleat th erapis ts (or sto ry te llers ) m ay not do the same things the

same w ays, they ce rtainly deal with sim ilar themes: confusion,

frustration, anger, meaninglessness, loneliness and alienation,

powerlessness, help lessness , and fear and dread .

Toward a Consensus

In 1985 the first “Evolution of Psychotherapy” conference was

held; two dozen of the wo rld’s m ost pro m inen t the rapists were


36/234


invited to prese nt the ir views and respo nd to othe rs’ ideas. T he

stated mission of this auspicious event was to build on one

another’s work and integrate commonalities among the variousideas. These were, after all, the most brilliant minds in our

profession; surely they could devote th eir energ ies toward finding

common ground.

In reviewing a dialogue between object relations theorist

Jam es M asterson and family therapist Ja y H aley at this con

ference, we are witness to an event that has become so com

mon in our field: the skewing of one person’s ideas in an effort

to elevate one’s own approach.

M asterson begins with the presentation o f his ideas abou t how

the developm ental object relations app roach evolved. H aley com

ments that (1) these ideas have died long ago; (2) the phenomena

tha t were discussed do no t exist; (3) M as terson ’s obse rvations

are cloudy and ill-formed; (4) his attitude is so rigid and fixed

that he cannot see what is really going on; and (5) Haley’s own

ideas make a lot more sense.

M asterson retorts to H aley tha t (1) he is wrong; (2) he is not

reflective and thoughtful; (3) he is so negative, rigid, and fixed

that he cannot open his mind to other possibilities; (4) he mis

understands Masterson and his ideas; (5) his ideas are better

than Haley’s.

If we were listening to children on a p layg rou nd , this would

sound comical. But we are not. Th ese are two of the brightest

minds in the field arguing about who has cornered the truth.

N either will budge from his posit io n. A nd we have heard the

same kinds of conflicting claims in thou san ds o f similar debates

over the decades.

Now, I have always found th is trem endously p uzzling—that

is, why do Masterson’s clients improve while he is working with

their individual dynamics of separation-individu ation, and yet

Haley’s clients also improve when he is realigning their family

hierarchies? And if this is not confusing enough, then how do

we accou nt for R og ers’s effectiveness w hen he is empathetically

resonating with his clients, or Ellis’s successes by confronting

irration al beliefs? T he re are, of course, m an y oth er variations

that are equally effective.


37/234


In his analysis of the trend s that em erged d uring an “Evo lu

tion of Psy cho therapy ” conference, Zeig (1986) concluded that

once upon a time, all of the therapists in attendance were considered mavericks, considerably ou t of the m ainstream in their

thinking. As such, they were forced to limit their focus in at

tempts to protect their provocative ideas from attack. Now, how

ever, their theories are the m ainstre am —and their proselytyz-

ing seems to reflect rigidity and an extreme c om m itment to their

own perspectives. Zeig sees little chance there will be much con

vergence among the different therapeutic approaches; he finds

the authors of the various theories to be too stu bb orn, too committed to perpetuating their own ideas, too territorial in their

thinking, to be open to greater cross-fertilization.

This, I think, is a tragedy. It is time to stop fighting among

ourselves about which theory works best and about which of

us really und erstan ds the true n atu re of reality. T o gain grea ter

respectability, efficiency, and efficacy, we would be much bet

ter off if we took the advice we give o u r clients: Let go of rigid

beliefs that keep us from growin g. Stay open to new possib il ities. C reate an individually designed set of values, b ut one th at

fits with w hat others are doing. U nify our experiences. Sy nthe

size w hat we know and u nd ersta nd into ideas we can use. In te

grate the past with the present and future, the person we are

with the person we would like to be. Confront the paradoxes

and polarities of life and resolve them by c reating a whole be

ing greater than the sum of its parts.

T he com pleat therap ist is, most of all, someo ne who takeshis or her own advice.


38/234

C h a p t e r T w o

The Struggle to Find Things

Therapists Can Agree On

O n e would think th at the fellowship of professional therap ists

would be a fairly cohesive group, unified in the promotion of

services and m utua lly su pp ortive o f one an oth er’s efforts. But

this could no t be furth er from the truth . It is the na ture of ou rspecies to be territorial, to stake out our boundaries of private

space with fences and other de m arcations o f ow nership. Th is

is true not only with our land, but with our ideas. Since the

begin ning of recorded his to ry, we have evidence th at wars over

competing ideologies, religions, o r life-styles are a “na tu ra l” way

of life for hu m an beings. A nd these battles go way beyo nd ra

cial, ethnic, or national boundaries.

T he tribal wars between co m peting schools of thera py are vicious, but ra ther than throwing spears at one ano ther, we seek

to discredit our adversaries through more subtle means. Sit in

on the staff m eeting o f a large clinic and watch everyon e go at

it —the psy chiatrists versus the psychologists versus the social

workers versus the counselors versus the psychiatric nurses, each

group believing they are truly jus t an d do things the w ay they

are intended to be done. Then, the ideological armies come into

play, all fighting for dom inance and control: T he psychoanalystsridicule the others for their lack of dep th; the behav iorists m ou nt

their attack, accusing the rest of ignoring the m ost salient features

of client change. T he hum anistic g roup sits patiently, plann ing

their own am bush by reflecting the feelings of an ge r and su pe r

24


39/234

The Struggle to Find Agreem ent 25

iority am on g their bre thre n, all the while feeling sm ug tha t they

really know what is going on. And these “global powers” are

all attacked by the upstart groups, the other 100 tribes who believe they have found what everyone else has missed.

In a cynical and hu m orou s p arody of therapists’ tendencies

to be “groupies” of a particular theoretician in vogue, Cham

berla in (1989) offers a step-by-step b lueprin t fo r how to be the

perfect discip le of M ilton Erickson. She provid es this advice be

cause E rickson represents one of the few schools of thou gh t tha t

still has openings for apostles (this is explained by the fact that

he did not write m uch himself, an d th at his work is so complexthat nobody really understands what he did). In order to be a

good Erick sonian, it is suggested that a disciple do the following:

1. W ear lots of purple (that was M ilton’s favorite color) .

2. Know at least one basic m etaphor (it does not have to make

sense —sometime s it is bette r if it does not).

3. Tak e vacations in Phoenix (vis it all the places M ilton used

to hang out; wear lots of purple).4. R epo rt a signif icant l ife-changing experience as a result of

yo ur contact w ith Erickson (since he died in 1980, you a re

allowed to include the impact of his videotape).

5. Get the jargon down pat (especially useful are induction,

trance, and intercontextural cues) so as to sound as much like

Erickson as possible.

Th is satire could, of course, be applied to any o rthod ox ap

proach currently in pra ctice. Psychoanaly sis , behavior th erapy,

gestalt, humanistic, rational-emotive, ego psychology, or stra

tegic family therapy all have their own disciples who pay hom age

to their creators, honor their memories, and flock together for

m utua l supp ort. W hile prov iding a degree of com fort to us in

affiliating with a pa rticu lar tribe, the resu lt of this “theory w or

ship” is the prolifera tion o f com peting schools all vying for power,

control, and a chance to be anointed the true heir to truth.

When Less Is More

In K uhn’s (1962) classic work on the evolu tion o f scientific dis

ciplines, he desc ribes a state of existence in w hich the re is no


40/234


single generally accepted view ab out the natu re o f a phe no m e

non. For example, before Newton and his colleagues in the

seventeenth century, there were dozens of com peting theoriesabo ut the n atu re o f light, each o f which m ad e sense to experts

at the time. It was New ton who w as able to pull tog ether these

diverse schools of thou gh t into a single organ ized p arad igm with

a set of established rules, standards, and directions for future

research.

Pen tony (1981) suggests that the prep arad igm atic stage psy

chotherapy is currently in is remarkably similar to the chaos

of com peting schools of physics before the seven teenth c entury .H e endorses K uh n’s observations on the deve lopm ent o f science

in general to the ev olution of psych otherapy in p articular —

that is, that in the absence of a un ifying pa rad igm , efforts should

be directe d to w ard develo pin g one that will help to in crease

cooperation and decrease com petition am ong scientists and prac

titioners. C on tinuing to gathe r more facts, ge nerating m ore data,

and proliferating m ore theories to explain the na ture o f hu m an

dysfunction and change only exacerbates the problem of having more concepts than we could ever deal with. As Pentony

(1981, p. xiii) explains: “W ha t is called for seems to involve a

special kind o f theo rizing . ‘B rea kth rou gh s’ in science seem to

come from a way of thinking th at pen etrates into theory, re

veals som ething of the assum ptions tha t are involved in it, an d

in doing so opens alternative ways of con templating the phenom

ena—ways which at first glance seem strange and unreal but

which, when their implications are reached, seem obvious.”W e do not need m ore theories of psycho therapy; we need

fewer of them . W e need unifying principles of helping that sim

plify th e confusio n of com petin g concepts , tha t describ e th e es

sence of effective psych otherapy and provide gene rally accepted

prin cip le s that most clinic ians could subscrib e to . In fact, this

m ovem ent has begun in the past decades, mo st notably by those

such as Gregory Bateson and company, who sought to discover

the underlying basis for hum an com m unication; by C arl R ogers,Robert Carkhuff, and colleagues, who have tried to describe

the core cond itions of helping; an d finally, thro ug h the most

recent efforts by dozens o f w riters an d th eore ticians w ho have

been attem pting to reduce th e existing chaos.


41/234

The Struggle to Find Agreement 27

There have been a number of systematic attempts to inte

grate diverse elem ents of effective psych othe rapy into a unified

system of helping. Some o f these efforts are sum m ed up here:

1. Eclectic models. Eclectic models are presented or critiqued

by W oody (1971), T horne (1973), Dyer and V riend (1977),

Garfield (1980), Palmer (1980), Goldfried (1982b), Beutler

(1983), H ar t (1983), Driscoll (1984), Held (1984), P rochaska

and DiClemente (1984a), Fuhriman, Paul, and Burlingame

(1986), Howard, Nance, and Myers (1986), Kanfer and

Schefft (1988) and Egan (1990).2. Single theories that have synthesized attributes from a fe w other models.

For synthesizing theories, see French (1933), K ub ie (1934),

Do llard and M iller (1950), L ondon (1964), Birk and Brink-

ley-Birk (1974), Kaplan (1974), Watzlawick, Weakland,

and Fisch (1974), Bandler and Grinder (1975), Bandura

(1977), Wachtel (1977), Lazarus (1981), Fensterheim and

Glazer (1983), M urga troyd and A pter (1986), E rskine and

Moursand (1988), Kahn (1989), and Duncan, Parks, and

Rusk (1990).

3. Collections o f research on wha t makes therapy effective. Studies in

clude G urm an and R azin (1977), M arm or and W oods

(1980), Rice and Greenberg (1984), Garfield and Bergin

(1986), G reenb erg and P insof (1986), K anfer and G old

stein (1986) and Norcross (1986).

4. The nonspecific major facto r approach that seeks variables common

to most methodologies. On this approach, see Rosenzweig

(1936), H obbs (1962), T ru ax and C arkh uff (1967), F rank

(1973), Strup p (1973), M arm or (1976), Co rnsw eet (1983),

K arasu (1986), O m er (1987), D ecker (1988), M ah rer (1989),

and Patterson (1989).

5. Recent integrative approaches to the treatment o f specific problems.

To cite only a few examples, integrative approaches have

been applied to anorexia nervosa (Steinlin an d W eber, 1989),

bulimia nervosa (Johnson and C onno rs, 1989), the child molester

(Barnard, Fuller, Robbins, and Shaw, 1989), selfmutila tion

(Walsh and Rosen, 1988), cocaine addiction (Washton, 1989),

phobias (Wolfe, 1989), su icidal clients (Bongar, Peterson,

Harris, and Aissis, 1989), borderline clients (Kroll, 1988), au-


42/234


tistic children (Konstantareas, 1990), and narcissistic disorders

(Gold, 1990).

It is in this tradition o f un ification, c oo pera tion, simplifica

tion, and synthesis that the present work was undertaken. I am

attem pting to answer the question, W hat can we be reasonably

sure makes an effective therapist?

The Advantages of Integration

The search for what makes therapists universally effective isgrowing. T he m ajority of practitioners, in fact, are u nd ertak

ing such a task ind epen den tly —trying to sort out for themselves

wha t colleagues are doing and why, and how new learnings from

readings, workshops, conventions, informal discussions can be

integrated into one’s existing practice. Most clinicians are be

coming m ore and mo re uncom fortable with the labels that iden

tify them as disciples of any particular school, preferring instead

the term eclectic to mean only that they are somewhat flexible.

In a survey of m ental health practitioners rep resenting four

different professions, Jensen, Bergin, and Greaves (1990) con

firmed previous studies that the vast majority of practitioners

(68 percent) describe themselves as eclectic in th eir orien tation.

They also noted that among the 423 therapists in the national

sample the trend seems to be moving toward integrative attempts

betw een four divergent theorie s (psychodynam ic-hum anis tic-

cognitive-behavioral com binations, for example) ra the r than jus t

com bining those that are already closely aligned (cognitive and

behavioral, for example ).

It would appear, then, that one of the most significant chal

lenges for contem porary clinicians is neither the m astery o f the r

apeutic skills nor the learning of new interventions; it is the

blending of what th ey know, understand , and can do in to an

integrated m odel of practice. C ertainly , we are not very well

prepared for such a task. M ost o f us were indoctrinated in to

particu lar schools of thought w hen we were young and im pres

sionable. O u r professors and m entors tried ha rd to influence

our theoretical allegiances along lines compatible with their


43/234


own —and they were largely successful (Sam m ons an d G ravitz,

1990). We were not adequately instructed in the methods by

which to pull together diverse points of view and conflictingideas. Instead, we were after simplicity; things were complicated

qu ite eno ugh as they were —trying to stay in the g ood graces

of ou r teachers, m aintaining the approva l of ou r supervisors,

and n ot losing too ma ny clients. A dv entu rism, creativity, bu ck

ing the system with too much flexibility might jeopardize our

already vu lnerable positions in the professional hierarchy. It was

easier to follow the party line, that is, until we got out into the

field and discovered that our clients did not care what theorywe were using; they just wanted results.

In spite of the difficulties inherent in trying to reconcile con

flicting opinions, divergent philosophies, sometimes even radi

cally different assum ptions rega rding treatm en t goals, there are

several reasons why the m ove m ent tow ard integration will only

continue to flourish:

1. I f we know w hat aspects of a therapist ’s behavior and being are most powerful and influential in promoting success

ful treatment outcomes, we can concentrate our efforts on

refining skills and sorting out the specific ways in which

they can be more optimally helpful. This can take place

along the usual lines of trying to sub stantiate these assu m p

tions through empirical research, as well as through the

efforts of practitioners who can m on itor th eir m ethods and

those of their colleagues to observe com m on deno m inators.

2. Th ere is increasing frustration and impatience with the bick

ering that has existed among theoreticians in the field for

the past decades. E ach pro po nen t of a particu lar approach

seeks to convince the world that his or her methods work

better than any oth er. T oo m uch energy has been in vested

in disputing the wrongness of what other professionals do,

rather than in figuring out the rightness of wh at everyone

seems to be doing.3. I t is somewhat em barrassing, when one thinks about it, to

consider that the state of affairs in the therapy profession

is such that there is so little agreement (at least publicly)


44/234


as to what constitutes effective therapy. The prospective

client is faced with the task of choosing a helpe r am on g those

who say it is best to add ress sym ptom s in a direct way, those

who claim it is better still to examine unresolved conflicts

in the past, those who favor attention to thinking processes

or to affective states, those w ho say talking things ou t is most

im po rtant, while others believe that being retraine d, recon

ditioned, or rein do ctrinated into new ways of beh aving is

most ap pro priate. T he sum total of this chaos is that it does

not seem like we really know why a nd how the rap y works.

4. There are mount ing pressures from th i rd-party re im burse

m ent organizations to produce changes within certain time

param eters. T his has forced clinicians to be m ore adaptive

in their approaches, doing some things with clients who have

the inclination and resources to work in long-term treat

ment and doing other things with clients who are interested

in different goals (Norcross, 1986).

5. In tegra tion means, for M ahrer (1989), reducing the num

ber of theories in the field to a m ore m anageable num ber

in ord er to establish a com m on m arketplace o f specific oper

ations and a shared vocabulary of terms with common

meanings.

6. I t would be so much more useful in our teaching and su

perv ising of beginning therapists to focus less on indoctr in at

ing them into a specific system, and to concentrate more

on the generic skills (such as emp athic reson ance) and atti

tudes (such as multicultural sensitivity) that most often make

a difference. There are, however, many distinct advantages

to affiliating with a particu lar theoretical app roach, the most

im po rtant of which is that it narrow s the scope of ou r work

to manageable limits; it is just too overwhelming to keep

up with advances in all the different approaches and it is

too impractical to maintain competency in all the various

interventions. In other words, I am urging greater flexi

bil ity in our th inking and a greater willingness to adopt

aspects of competing schools that we might find useful.

As convincing as these rationales are for creating a more in

tegrative profession, there is also tremendous resistance, espe-


45/234


dally from those theoreticians who are vested in keeping their

own ap proac hes “pu re” an d u nd iluted by oth ers’ influence. In

a volume devoted to the presen tation of the dozen m ajor systems of eclectic thera py , D ryden (1986) was stunne d to discover

that the contributors, who advocated so strongly a cross-fertil-

ization of ideas, d id no t refer to, o r draw on , each o ther ’s work!

Even these eclectic theoreticians, who are committed to the in

tegration o f research, finding comm onalit ies am ong diverse ap

proaches, and following a plu ralistic, flexible approach, did not

particularly acknowledge th e work of colleagues w orking along

para llel courses.

Eclecticism, Pragmatism, Pluralism

Th e reduced influence of individual systems is du e not only to

the burgeoning number of new additions each year, or to the

fierce debates that are waged between competing schools, but

to skeptics within the ranks. Omer and London (1988) review

three of the m ain app roac hes th at are b eing slowly modified by their own proponents . W ith in psychoanaly sis , fo r exam ple ,

m any clinicians no longe r accept F reu d’s notions tha t it is pos

sible to unearth “truth” from the client’s memory or that the

analyst should be a completely neu tral figure. A m ong b ehav ior

therapists there is skepticism reg arding the value o f learn ing theory

in explaining all behav ioral ph eno m ena or the app ropriateness

of dealing with only observed behaviors. A nd m any cognitive

therapists qu estion the value of den ying affective dim ension sin favor of exclusively concentrating on cognitive processes.

The application of specific app roaches has evolved into a new

series of schools with different na m es a nd bro ad er scopes: tec h

nical eclecticism, pluralism, pragmatism, nonspecific factors,

microinvestigations, a nd treatm ent m anu als are representative

of the new diversity and synthesis. As O m er a nd Lo ndo n (1988,

p. 178) expla in : “Diffe re nt responses to th e system s’ collapse

chiefly reflect different a ssum ption s o f the systems’ era: Ec lecticism does away with technical pu rity; the nonspecific app roac h

denies the imp ortance of conceptual differences between systems;

plu ra lism waives exclusivism in favor of rela tivism ; m ic ro in ves

tigators dismiss the systems’ un its o f analysis in favor o f smaller


46/234

32 T he Com pleat Therapist

and more

the compleat therapist

Documents