Therapist as Neighbor

I’m sure I’m not the first to draw a parallel between Fred and Carl Rogers. Both men have captivated millions. Both men prized warmth, empathy, safety, and inter-personal engagement. And in both Mr. Rogers’ show and Mr. Rogers’ session, everybody feels good, but not much happens.

I am no expert in the history of clinical psychology, but it seems like Carl Rogers deserves credit for the meme “therapist as paid friend,”—i.e., the therapists who are sufficiently nice to you, but don’t help you set goals and learn strategies to accomplish those goals. This week’s two articles Kirschenbaum and Jourdan’s article “Current Status of Carl Rogers and the Person-Centered Approach,” and Castonguay, Constantino, and Holtforth’s “The Working Alliance” offer no consolation—but they may offer explanation—to those of us who feel that they’ve paid about $100 an hour for a lot of really great eye contact.

Do not get me wrong, I wholeheartedly embrace the primacy of the therapeutic relationship and Rogers’ trio of core conditions: empathy, positive regard, and congruence. However, they seem more like prerequisite personality traits of clinicians. Can you even train empathy and warmth? Can you manualize it? I also wholeheartedly agree with Rogers and his followers that not one, not two, but all three conditions must be present for therapy to be “sufficient.” But sufficiently what? Yes, sitting on a comfy couch in the presence of a lovely therapist may be sufficiently, uh, pleasant? But how about raising the bar a little from “sufficient” to helpful. Could we even try, where needed, to be transformative?

Though many significant effects of Rogerian sufficiency are reported, few effect sizes are. Empathy, positive regard, and congruence, while clearly a necessary foundation for therapy, seem quite insufficient as a therapeutic technique or method. C, C, and H admit that while preliminary findings about the effectiveness of techniques designed to foster alliance are promising, “we need more convincing evidence… that such techniques have direct, unique, and causal effects on improvement.” Any mention of psychological mechanisms responsible for clients’ improvements in person-centered therapy is similarly murky. Again, my harshness may be due to not knowing enough about person-centered therapy, but it actually seems more about the therapist’s behaviors, how she should act. What are the strategies offered to the client?

Is it just me, or are this week's readings really Pomo?

This week’s authors seem as captivated by Postmodernism as contemporary artists, writers, and movie makers who may more readily garner the term. Perhaps I’m just stuck in a bygone undergraduate art history major way of reading articles and thinking about things. Or perhaps I shouldn’t at all be surprised that Postmodernism has seeped into psychology. Or, to be Postmodern about it, perhaps both.

Questioning assumptions; dissolving stark dichotomies; converting accepted facts into narrative “texts;” weaving together appropriations; getting “meta-” about things: Westen, Novotny & Thompson-Brenner (2004) and Smith (1999) traffic in all of these. W, N, & T begin by proposing (per Robert Abelson, 1995) that “the function of statistics is not to display ‘the facts’ but to tell a coherent story.” The authors then parody the rise of Empirically Supported Therapies (ESTs) in a pseudo-Arthurian tale starring the “Knights of the Contingency Table,” and ending in the qualified success of empirically supported therapies. Then, the authors revise the parody, writing in a more troubling ending involving oversights, untested assumptions, client relapses, biased funding, and “invoking the name of Empirical Validation” in vain. The two narratives merge into a palimpsest.

W, N, & T send the vaunted notion of “empirical support” through the wringer, emphasizing the validity of properly designed meta-analyses over blockbuster studies funded by drug companies. “Empirical support is not a dichotomous variable,” is W, N, & T’s concise entrée into the deconstruction treatment outcome studies that neglect the long-term view of patients’ struggles, which often include relapse. W, N & T also advocate consumer access to “details essential for assessing the internal and external validity of even high-quality studies.” This shrinking space between those with information/power and those without invoked for me the Postmodernist practice of collapsing the space between artist and viewer, or “breaking the fourth wall” in theater.

Cherished classifications of theoretical orientation are Smith’s target in “The End of Theoretical Orientations?” He proposes “a new kind of meta-theory of therapy.” This meta-theory isn’t a static code but more of a process, or, as Smith puts it, “a creative act.” When faced with patients who elude easy diagnostic categorization, “one must abstract pertinent change principles from the empirically supported procedure for a different condition, and then through a creative act, translate that principle into a plan for the situation in which the procedure is untested.” Certainly this “activity” is best performed by the Super Clinicians that W, N & T describe at the end of their article: “clinically competent decision makers (rather than paraprofessionals trained to stay faithful to a validated manual) who have the competence to read and understand the relevant applied and basic research, as well as the competence to read people.

Unlike many Postmodern artifacts in which so much questioning and deconstruction leads to a sense of absurdity or meaninglessness, these articles are wildly constructive. They don’t grind us down with their knowing allusions and dark ironies; instead they rally the reader to think in new ways about therapy.

Mining Meta-anaylses, Hunting Dodos: Why We Love 771

I have to admit that during my reading of Chambles and Hollon, I suppressed urges to email old friends and go eat ice cream, but succumbed to cutting my toenails. Perhaps in part because I read it at the end of the day when I was a little drained, I found this article difficult follow and kind of a downer. I think it was a dizzying downer for me, however, because it’s a rigorous survey of the seemingly infinite number of pitfalls of something I think is infinitely important: testing whether therapies that sound good really help people. C and H are critically skeptical and highly conservative in their unpacking of therapies outcome research. C and H have us thinking, wow. That’s really hard to do right. ("No one definition of sound methodology suffices for all areas of psychological treatment research.") But C and H fueled my determination to attain methodological sophistication and not repeat others’ mistakes when testing my own interventions (which I sincerely hope to do for my own dissertation). I especially love the Appendix, “Summary of Criteria for Empirically Supported Psychological Therapies”— i.e., The Five Commandments for evaluating empirical support. Good to keep close at hand.

Hunsley and DiGiulio provided my first exposure to “the well-known ‘Dodo bird effect.’” The Dodo stars in a cautionary tale straight out of Chambles and Hollon: a few spurious arguments and some badly designed meta-analyses deemed therapeutic treatments to be equivalent, and that idea really caught on. Once the statistical errors in these meta-analyses were corrected, the Dodo effect turned out to be entirely inaccurate, and cognitive and behavioral treatments reign supreme. One wonders what other fallacies permeate psychology today, fallacies without colorful names, or even names at all.