Psychotherapy as a Developmental Process

Michael Basseches, Michael F. Mascolo

• Publisher: Routledge
• Year: 2009
• Print ISBN: 9780805857306
• eBook ISBN: 9781135598655
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

For all those engaged in psychotherapy practice, regardless of modality or approach, the goal of this book is to provide a framework and method for thinking about their work that allows for critical reflection on their own successes and disappointments, and on the similarities and differences among their own and other practitioners' work with different clients. The authors use a novel "common factors" approach, based on the idea that some form of development is the outcome of all effective psychotherapy, despite other differences that may exist.

While most existing psychotherapy research focuses on treatment outcomes, primarily in terms of symptom reduction, this book offers an alternative research approach that systematically tracks the psychotherapy process itself, and describes each case's unique developmental outcome. In particular, Basseches & Mascolo focus on the questions of what kinds of therapeutic resources therapists are offering to their clients and whether and how clients are able to make use of these resources in the service of their own development.

The goal is to provide a descriptive framework that can be used to appreciate the highly varied ways in which particular therapists tailor their work to unique clients' developmental needs, while at the same time offering a prescription of a more rigorous method for recognizing and correcting the problem when a particular therapist's way of working is not serving the client well. Ideally, this type of process-focused research will complement existing outcome research, and be more likely than further symptom-reduction studies to result in the improvement of overall psychotherapy success rates.

Part 1

Introduction

CHAPTER 1

Psychotherapy and Development

Goals of This Book

Psychotherapy and development represent two central concerns of practitioners, theorists, and researchers—both within the field of psychology and far beyond disciplinary bounds; both within the contemporary zeitgeist and over the histories of various related disciplines. How are we bringing these concerns together in this book, and why?

Our primary audience is the broad community of practitioners, researchers, and students of psychotherapy.¹ The term psychotherapy practice refers to an extremely broad and variegated set of phenomena. The tremendous variation in manifestations of psychotherapy practice is attributable to at least the following five factors, among others: (a) variation among the personal styles, repertoires, and relationship histories of individual practitioners, all of which influence the way the psychotherapy process unfolds; (b) variation in the schools, theories, and techniques in which therapists have been trained, in which the differences appear so great that practitioners trained in these traditions seem to speak in technical languages that are often so different from one another that communication across the boundaries of these traditions is an almost overwhelming challenge;² (c) variation in the forms of therapy (group therapy, couple therapy, family therapy, individual therapy, milieu therapy, psychodrama, community intervention, etc.), which leads to very different patterns of interaction; (d) variation in the setting of therapy (private practice, college or school counseling center, community health center, hospital, etc.), which also leads to major differences in how the process is manifest; and (e) variation among the clients—in terms of age, gender, culture, socioeconomic class, and the problems and processes that led to their presenting themselves for psychotherapy. For all those engaged in psychotherapy practice, our goal in this book is to provide a framework and method for thinking about their work that allows for critical reflection on their own successes and disappointments, and on the similarities and differences among their own and other practitioners’ work with different clients.

Our approach to providing such a framework and method is a “common factors” (Carere-Comes, 1999, 2001) approach, based on the idea that some form of development is the common outcome of all effective psychotherapy, all differences notwithstanding. Our effort is to describe and track the fundamental common processes that facilitate development within all forms of therapy, and to understand how these processes are obstructed in cases where the therapy is not effective.

Psychotherapy research also comprises a wide range of activities. Nevertheless, one basic research paradigm has dominated such research (Peters, 2008). This paradigm entails treating outcomes, primarily measured in terms of symptom reduction (both immediately after therapy and over time), as dependent variables, and treating client diagnosis, therapist technique and training, and length of therapy as primary independent or mediating variables. There is also a concomitant attempt to develop quantitative measures of other mediating variables, such as strength of therapeutic alliance, degree of therapist–client demographic match, and aspects of therapists’ and clients’ personalities. Although many therapists are indeed concerned with reducing some of their clients’ “symptoms,” and that this is done in a cost-efficient manner is certainly a major concern of third-party payers who fund a great deal of psychotherapy, in our view this research paradigm generates understandings that are only tangentially related to what inspires, guides, and motivates most therapists in their work. Furthermore, most meta-analyses of psychotherapy research studies have suggested that no one therapeutic approach is clearly superior to others in terms of outcomes (Cuijpers, van Straten, & Warmerdam, 2008; Luborsky et al., 2003), and some research has cast doubt on whether a therapist’s training makes any significant difference in therapeutic outcome (Dawes, 1994). Although research that leads to the documentation of a particular standardized therapy technique as an “empirically supported treatment” does provide some encouragement to practitioners, teachers, funders, and consumers of psychotherapy, it is debatable whether this entire outcome-oriented research enterprise has led to a greater overall success rate in psychotherapy practice.

For all those interested in psychotherapy research, our goal in this book is to offer an alternative research approach that systematically tracks the psychotherapy process itself and describes each case’s unique developmental outcome (rather than relying on more general outcome measures that do not relate to the client’s unique individual concerns). In tracking the psychotherapy process, we focus on the questions of what kinds of therapeutic resources therapists are offering to their clients (and clients to each other when the therapy involves more than one client), and whether and how clients are able to make use of these resources in the service of their own development. We also look at processes of mutual adjustment of what therapists learn to offer and what clients learn to use. We believe that this research approach is more compatible with the way most therapists approach their practice than the search for technique–outcome correlations. We furthermore hope that this type of process-focused research will complement existing outcome research, and be more likely than further symptom reduction studies to result in the improvement of overall psychotherapy success rates.

So our starting point is the idea that psychological development represents a common outcome of all effective psychotherapy. Is this a radical idea, or is this an assumption that most therapists, across the widely divergent psychotherapeutic traditions, already make? Perhaps this depends on how psychological development is defined and conceptualized. Is it methodologically possible to rigorously assess and track psychological development as it occurs within the psychotherapy process? Again, this depends on our ability to conceptualize psychological development and to operationalize the measurement of psychological development as it occurs in the context of human relationships.

For these reasons, we will turn our attention at the outset of this book to what we mean by development, and how we study it. We will clarify the intellectual traditions on which we draw in understanding the concept of human development. Also, we will try to locate where we stand on some of the controversial issues that have arisen in life span developmental psychology, particularly as it is applied to professional practice.

This will provide a foundation for the work that will make up the core of this book—the presentation of our proposed method of analysis; a discussion of its relationship to the goals, models, and methods of extant approaches to psychotherapy; an analysis of the role of emotion in psychotherapy; and illustrative applications of this method to psychotherapeutic case material. In the final section of the book, we will consider the implications of our approach for psychotherapy practice, research, and training, as well as for developmental psychology.

Before initiating our systematic discussion of how we conceptualize development, and the intellectual traditions on which we draw, we would like to share an anecdotal account of what happened when the first author presented this work for discussion to a group of his practitioner colleagues. The discussion that ensued quickly raised issues of the ways that a book like this might be appropriated and/or misappropriated.

The presentation began with the statements that the authors are interested in “common factors” in all forms of psychotherapy practice; that our focus is on the common processes that foster development within all forms of psychotherapy, in cases in which the therapy is successful; that we are particularly interested in the range of additional resources that therapists offer that can be utilized by clients in the service of their development; and that we believe that cases in which psychotherapy is unsuccessful can be understood as instances of the client being unable to make developmental use of the resources that the therapist is offering and, conversely, of the therapist being unable to offer resources that the client can use. Then, our research method for tracking the developmental movements that occur within psychotherapy, the resources that the therapist offers, and the client’s use of these resources was described in a bit more detail.

In the ensuing discussion, following an exercise in which participants were invited to look at their own experience of practice through the lens of developmental analysis, two participants³ soon articulated the key question: Is this framework intended to be descriptive or prescriptive? This question strikes to the heart of the current relationship between psychotherapy practice and psychotherapy research, and to the contribution to that relationship that this book is intended to offer.

If one looks at what currently guides psychotherapy practitioners in their practice, one finds an abundance of theoretical frameworks and therapeutic techniques. Each practitioner describes his or her work in the languages of the theoretical model(s) in which he or she has been trained, and cites any specific techniques that he or she has learned to employ. Most therapists further acknowledge the role of their own personal styles in the way in which they build relationships with clients and make choices about which conceptual and technical tools to employ in their work with any given client. Most therapists also acknowledge that various kinds of “value judgments” influence their choices throughout the entire process of therapy, from the establishment of goals, through choices of where to focus and what positions to adopt in any given session, to decisions related to termination.

It is not unusual for therapists to encounter reports or presentations on new research and/or on innovations in therapeutic technique. (The techniques and research findings may be conjoined when a technique is presented as an “empirically supported treatment.”) Sometimes these encounters occur in the context of continuing education, which the therapist seeks to foster his or her own professional development. Sometimes the encounters occur in the context of the pressure that therapists may feel from third-party payers or regulators, to make sure that their practice is both efficient and consistent with evolving standards of care. But in either case, the therapists are often asking the questions “What is this presentation suggesting that I do that is new and different from what I am already doing?” and “Is this adaptation one that I am willing and able to make?”

In this context, it seems important for us to clarify that the primary effort of this book is descriptive. The goal is to describe systematically how therapists, in doing the range of things that they already do, help to support their clients’ development. A further goal is to provide a common language in which therapists trained in differing approaches and techniques can discuss and appreciate the similarities, differences, and complementarities within what they already do. But the goal is not to present a new and different approach for therapists to adopt in working with their clients, nor to suggest that therapists abandon their particular ways of working in favor of a more standardized approach.

On the other hand, there is another sense in which the intent of this book is prescriptive. First, we are prescribing that therapists reflect on whether progress is being made in their work with each individual client. Although this is something that conscientious therapists already do, and that psychotherapy research is intended to support, we offer a set of concepts and methods that we hope will be more helpful in this effort. And although these methods may entail the therapist taking a step outside the conceptual framework through which he or she usually, on a day-to-day basis, views his or her practice, they involve close inspection of the presence or absence of movement in the client’s own unique meaning making. They are not likely to be experienced by the therapist as the imposition of assessment of the relationship from an external, nomothetic frame of reference, as is often the case when therapy is subjected to evaluation by managed care reviews or efficacy research. Finally, we are indeed prescribing that when therapists discover that their work with a client is stuck with respect to developmental progress, they attempt to diagnose and treat these obstacles to development by considering the alternative forms in which they may offer developmental resources to this client.

In sum, the current relationship between psychotherapy practice and psychotherapy research is often experienced as a struggle, in which psychotherapy research is experienced as prescriptive, using large numbers of research subjects and general measures to establish “standards of care” to which practitioners are expected to adapt. Therapists often respond by rejecting research that seems to come from a foreign frame of reference, uncritically reasserting their personal “intuition,” “clinical experience,” and “knowledge of the particular client” as adequate foundations for their work. In contrast, this book is an effort to provide a descriptive framework that can be used to appreciate the highly varied ways in which particular therapists tailor their work to unique clients’ developmental needs, while at the same time offering a prescription of a more rigorous method for recognizing and correcting the problem when a particular therapist’s way of working is not serving the client well.

It would be a misappropriation of this book to interpret it as offering a novel way of doing therapy, or as suggesting the substitution of “developmental theory” or “developmental techniques” for the approaches to their work on which variously trained therapists have learned to rely. On the other hand, this work was appropriated by another one of the first author’s practitioner colleagues in exactly the way we as authors intend when she said at the end of the presentation,

It’s so important that we find ways to be reflective and self-critical about our work. I share with others here the sense that the work is really about “being with” the client. But I don’t want to assume I’m doing that just fine, that it doesn’t need any self-reflection. You’re offering a way to examine our work.⁴

With respect to the “value judgments” that the vast majority of therapists acknowledge repeatedly making, another advantage of viewing psychotherapy as a developmental process is that doing so provides a comprehensive framework in which these value judgments can be located and subjected to constructive, critical reflection. In the absence of such a comprehensive framework, we believe therapists rely on some combination of values drawn from a “medical model of psychotherapy,” the problems of which are considered in the implications section of the book;⁵ the therapists’ own personal likes and dislikes, whether (a) implicit or even outside of consciousness but reflected in their action choices, (b) explicitly but uncritically asserted, and/or (c) located and supported within a broader set of assumptions adopted by the particular therapist but not necessarily consensually validated by other therapists; and (d) values implicit or explicit in the theories of personality and psychotherapy on which they rely in their practice. Developmental frameworks, understood in the way we articulate in the next two chapters, do incorporate evaluative perspectives and assumptions. We hold that it is precisely because these frameworks have this prescriptive aspect that developmental approaches are appropriate frameworks for describing psychotherapeutic practice (and we hope and expect that they will be so experienced by psychotherapists).

Psychotherapeutic practice, like all educational practice, is not a valueneutral enterprise. It will inevitably be guided either by values that can be articulated and subjected to consensual affirmation, or by values that remain unarticulated and are more likely to be idiosyncratic, ethnocentric, or shared only by self-defined communities of “experts.”⁶ In the course of the chapters that follow, we will introduce discussion of the values or prescriptive assumptions that are entailed by our “coactive systems” view of psychotherapy as a developmental process, and how they might guide psychotherapeutic practice. This approach represents an alternative to the implicit prescriptivity of the medical model, which has a significant impact on how psychotherapy is curr...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright
• Dedication
• Contents
• List of Tables
• List of Figures
• Acknowledgments
• Part 1: Introduction
• Part II: Conceptual Foundations
• Part III: Method
• Part IV: Case Analyses
• Part V: Implications
• References
• Index