1-adopting a theory

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A d o p t i n g a T h e o r y

D eople have known and experienced the healing power of talking andrelating to other human beings since the earliest recorded times (J. D.Frank & Frank, 1991; W ampold, 2 001a ). In ancient societies, reparativetalk occurred m ost frequently with in religious practices, w hich w as th enthe dominant system of thought for making sense of our place in theworld. It wa s in the late 1800s that S igmund F reud introdu ced his "talking cure"the modern Western concept of psychotherapy. By doing so,Freud wrested therapeutic conversations from the domain of religionand into secular medical practice. Soon thereafter, p hysicians, social work e r s , psychologists, counselors, and others undertook therapeutic conversations with adults, children, families, and couples in an effort to curean y n u m b e r o f i n d i v i d u a l , s o ci al , an d co m m u n i t y i lls . I n m o s t W es t e r ncultures, psychotherapy is now generally accepted and valued as a helping modality that can reduce human suffering and improve our qualityof life.In the time following Freud, psychotherapy has come to be understood as a unique craft that requires specialized skills to achieve remedialresults (Freedheim , 1992). Also during this t ime, how ever, a plethora ofapproaches to psychotherapy with apparently incompatible ways of conceptualizing therapeutic practice have emerged. These include psychodynamic, behavioral, existential, person-centered, gestalt, cognitive, systemic, feminist, and constructivist approaches, among others. Indeed,theories of psychotherapy have proliferatedconservative estimates arethat there are some 250 distinct approaches (Goldfried & Wolfe, 1996)to the point that not one of them can claim dominance.


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4 B E C O M I N G A N E F F E C T I V E P S Y C H O T H E R A P I S T

The task confronting the modern practit ioner of healing conversation, therefore, is how to choose one form of therapy over another. Theanswer l ies in understanding how psychotherapy works.

How DoesPsychotherapy Work?Evidence based on over 40 years of research, involving hu nd red s of studiesand thousands of clients, provides consistent support for the conclusiontha t psy cho ther apy in its m an y diverse forms is highly effective (Lam bert& Ogles, 2004). The effect size (i.e., the statistically standardized differencebetween the averages of two groups) of psychotherapy on personal distress for those receiving it compared with those who do not is 0.80(Wampold, 2001b). This is a large effect (Cohen, 1988), and in practicalterms it means that the average person who receives psychotherapy isbetter off than 79% of those who do not and that psychotherapy accounts for 14% of the variance in mental health outcomes (Wampold,2001b) .

Given that psychotherapy is effective and given the number of different theories with their often very different conceptual principles, prescribed interventions, and procedural proscriptions, a reasonable question to ask is. W hich o ne of the m is correct? Which th eor y explains ho wpsychotherapy works and therefore is the one that should guide practice? The studies that support the efficacy of psychotherapy also overwhelmingly support another very important conclusion: There are nosignificant differences in the effectiveness of any system of ps ych othe rap yover anoth er (Ahn & Wam pold, 200 1; Chambless & Ollendick, 200 1;Lambert & Ogles, 2004; Wampold et al , 1997). Although there are somewell-conducted studies that have shown some differences between therapies (e.g., Dimidjian et al., 2006), the number of studies that show significant differences is what one would expect by chance given the totalnumber of studies that have been conducted (Wampold et al ., 1997).Therapists ' belief in one theory over another, adherence to a particulartherapeutic system, or application of a specific treatment technique hasno consistent impact on whether they are more or less successful in relieving psychological distress or promoting mental health (Wampold,2007). Additionally, the benefits of psychotherapy are minimally, if at all,related to any specific treatment techniques, such as making transference interpretations, prescribing homework to dispute irrational beliefs,or role playing conflicted aspects of oneself (Ahn & W am pold, 2 00 1).These conclusions hold for both psy choth erapy in general and tr eatm ents


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Adopting a Theory 5

developed for particular disorders, such as depression (Elkin, 1994) andanxiety disorders (J. J. Sherman, 1998; Tarrier et al., 1999).

Some pract i t ionersand a good number of those who would tel ltherapists how they ought to practicehave difficulty accepting the absence of theoretical superiority or treatment specificity. Others find theseresults entirely consistent with their practical expe rience . Therefore, the reis considerable debate within the li terature about whether specific psycho thera pies hav e specific effects (e.g., Castongu ay & Holtforth, 2 005 ;Craighead, Sheets, Bjornsson, & A rnarson , 20 05; DeRubeis, Brotm an, &Gibbons, 2005; Kazdin, 2005; Wampold, 2005).

Of course, these findings typically exacerbate psychotherapists' anxiety: If one therapy is not better than another one is, then how does apsychotherapist decide how to practice? Without evidence-based guidance, are we not vulnerable as a profession to passing fads, where self-defined therapists can offer whatever they fancytickle therapy, sensory deprivation, or aura transmogrificationas viable treatments forserious m enta l health problem s? Perhaps w e need to ask a different question. Perhaps we ought to ask. How does psychotherapy work? In fact,the answer to this question can guide how we should practice.

Jerome D. Frank (1910-2005; see Figure 1.1), in his seminal workPersuasion and Healing: A Comparative Study of Psychotherapy, ex pla ine d th a tpsychotherapy works by establishing a circumstance that is characterized by thr ee aspects (J. D. Fran k, 1961; J. D. Frank & Frank, 1991). First,the treatment must involve activities consistent with a therapeutic rationale that is believable to the therapist and the client. Second, a clientm ust seek help from a practitioner w ho t he client believes to be helpful.Third, the client must experience a collaborative relationship with thetherapist. In support of this model, meta-analytic studies (Wampold,2001b) revealed that the most powerful effect sizes in relation to outcome are 0.60 for the therapist's belief in the treatment, 0.55 for therapist helpfulness, 0.45 for the degree of client-therapist collaboration, and0.40 for the client's belief in the treatment.

This understanding of how therapy w orks has a num ber of implications for prac tice. First, clients mus t seek th e he lp of the ther apis t. It is nocoincidence that the only form of psychotherapy to be tested and foundineffective is critical-incident stress debriefing, an approach in which individuals exposed to disastrous events are educated about the possible effects of exposure and encouraged to share their feelings and perceptionsabout the event (Mitchell & Everly, 1996). The circumstances unde r w hichit has been found to be ineffective were in hospital units where uninvited therapists debriefed patients who had medical treatment for earlym i s c a r r i a g e a n d b u r n s ( v a n E m m e r i k , K a m p h u i s , H u l s b o s c h , &Emmelkamp, 2002) .


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F I G U R E 1 . 1

Jerome D. Frank. Printed with permission ofthe Alan Mason ChesneyMedical A rchives.

Second, to be helpful, therapists should strive to collaborate with clients by establishing a com m on u nde rstan ding of the natu re of the client 'sproblem and an agreed-on means by which to bring about i ts remediation(Wampold, 2001a, 2007). Duncan, Miller, and Sparks (2004) called thisfinding th e c lient's theory of change. By finding a the or y of ch ang e th at isacceptable and believable for the therapist and the client, we can workcollaboratively toward shared goals through agreed-on tasks (Horvath &Greenberg, 1994). Sometimes the client will have an explicit model: "Iw an t to learn to express m y em otio ns." Often it is implicit: "If I could justfigure ou t w ha t is w rong w ith me , I w ould kn ow w ha t I nee d to do withmy life." In either case, it is not the ultimate truth of the model that ispredictive of cha nge ; it is th e s hare d belief in it. The relative w or th of a nyform of psychotherapy over another is not assumed. If the therapist hasa philosophical, logical approach to practice, for example, and the clienthas a pragmatic, action-oriented approach to life, then therapy is highlyunlikely to be successful. It would be just as likely to be unsuccessful ifthe therapist was behaviorally oriented and the client was predisposedtoward self-reflection and seeking personal insight. Although it may bepossible to convince clients that their understanding of their problemsand the solutions are incorrect and they should adopt the therapist 'sunderstanding, considerable time and effort will have to be devoted to


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Adopting a Theory 7

the task in proportion to the degree of dissimilarity, and there is no guarantee of results. Indeed, it is much more likely that clients will not return , an d the therapists as well as the clients will experience the other as"difficult" or "nonresponsive."Third, note that techniques are not entirely irrelevant to outcome.Rather, techniques are integral to effective practice if they constitute anactivity consistent with the tre atm ent r ationale and are a plausible m ean sby which to achieve desired results (Wam pold, 2001a, 2007 ). Stated q uiteplainly, you ne ed to do som ething during therapy, and w ha t you do oug htto make sense to the client.

Why Should IAdopt a Theory?If no theory is more effective than another, why adopt a theory at all? Atheo ry of practice is an org anized set of assum ptions that provides a framework for (a) generating hypotheses about what change processes willfurther therapeutic goals, (b) formulating specific tasks to facilitate desired change processes, and (c) evaluating progress toward the goals oftherapy. Theory serves as a heuristic that aids practitioners in selectivelyattending to and organizing the vast am ou nts of information available intherapy. Stated more simply, theory helps therapists know how to proceed. Having a the ory of practice is like hav ing a ma p of the psy cho thera peutic territory.

Practicing from a consistent theoretical base also helps therapists tobe more consistent in their practices and thereby better able to identifywhether trying something new is helpful. More than one writer has likened the relationship between theory and practice in psychotherapy tothat in music (Schacht, 1991). Just as a musician m ust be fully grou nde din musical theory to be able to improvise well, so too must a psychotherapist be grounded inwithout being bound bytheory.

Note that adopting a theory based on a particular system of psychotherap y is no t synon ym ous w ith preferring a particular intervention strategy. Behavior modification need not be the exclusive domain of behav-iorists or t ransference interpretat ion of psychoanalysts . Theoret icalpreference does influence how practit ioners behave in practicebehav-iorists are more likely to give instruction and psychoanalysts are morelikely to make interpretationsalthough not as much as most theoreticians w ou ld ha ve u s believe (Wogan & Norcross, 1985). Believing in atheory does lead to a preference for interventions consistent with ourassumptions about how to facili tate desired change processessuch asincreased frequency of new behavior or verbalizing ne w insightsas w e


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B E C O M I N G A N E F F E C T I V E P S Y C H O T H E R A P I S T

would hope. The challenge is to allow ourselves to remain open to alternative conceptualizations, as will be discussed in chapter 11 of this volume. Again, the idea is to be guided by theory, not blinded by it.

The most common approach to psychotherapy among pract i t ionersis eclecticism (Norcross, Pr och ask a, & Farbe r, 199 3), an ath eo ret ica l ap proach in which interventions are selected from any system of psychotherapy. The therapist selects proce dures that address the particular pr oblem presented by a particular client, rather than drawing only from thetherapist 's preferred theoretical system. From a pragmatic point of view,the merits of eclecticism are obvious: Do what works. After all, theory isfor therapists, not clients.

W hat seems to d raw therapists to eclecticism is the desire to be flexible in their approach to helping clients, that is, to be responsive to theuniqueness of client problems, characteristics, and circumstances. Seenin this l ight, we can appreciate the virtue of such an approach. Indeed,therapists with an integrative-eclectic approach are more likely to feelskillful and efficacious and to experience professional growth than thosew ho are allied with a single appr oach (Orlinsky & Ro nnestad, 2005 ).There is also some evidence that rigid adherence to the interventions ofany one theoretical approach results in diminished treatment effectiveness (Castonguay, Goldfried, Wiser, Raue, & Hayes, 1996; W. P. Henry,Schac ht, Str upp , Butler, & Binder, 1993 ; W P. Hen ry, Stru pp, B utler,Schacht, & Binder, 1993). Conversely, therapists w ho h ave n o salienttheoretical allegiance are more likely to feel ineffective, dissatisfied, andstagnant (Orlinsky & Ron nestad, 2 005) .

W ha t ma ke s ec l ec ti c ism espec i a l ly d if fi cu lt t o adop t as an ap pro ac hto practice, however, is that therapists still need some theory to guidetheir decision as to what technique to use with what problem for eachclient. In fact, most therapists who profess to be eclectic are practicing aform of syncretism in that they are applying interventions they are familiar and com fortable w ith in an essentially rand om m an ne r (McBride &Martin, 1990). There are hundreds of theories of psychotherapy, eachwith i ts own intervent ions. How could one pract i t ioner know how toapply the right intervention for the right client under the right circumstances to address all problems? Moreover, remember that interventionsdevoid of a shared, plausible rationale are not the active ingredient ofpsychotherapy.

For ou r purpo ses, eclecticism is problem atic because it does no t provide a framework for practice, placing practitioners at risk of losing theirw ay in therap y a nd thereb y failing to be helpful or actually causing h ar mto clients. In addition, w itho ut a plausible rationale w e do not ha ve common grounds from which to form a collaborative theory of change withou r clients, further decreasing the likelihood of a positive ou tcom e. Therefore, we need a mapthat is, a theoryto serve as our guide. However,


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Adopting a Theory 9

not just any theory will do; remember that our belief in the theory weuse is highly predictive of our success. W hat w e nee d is a theory in w hichw e can believe (Vasco, Ga rcia-M arques , & D ryden , 1993).

What TheoryShould I Adopt?The facts and methods of any scholarly undertaking, including psychotherapy, are based on assumptive worldviewsassumptions about the natur e of rea l i ty (How ard , 1985; Lyddon, 1989a; M aher , 200 0) . Anassumptive worldview essentially serves as a fil ter by which humans selectively attend to the vast amount of potential data available as they tryto understand the world around them (Koltko-Rivera, 2004), just as apsychotherapeutic theory helps psychotherapists to make sense of thepoten t ia l da ta in thera py (Hansen & Fre im uth , 1997; Poznanski &McLennan, 1995). At an individual level, one's worldview is one's personal the ory of ho w best to live his or her life (Prilleltensky, 1989; Unger,Draper, & Pendergrass, 1986). Preference for one the ory of therap y overanother is in large part dependent on the fit between that theory's basicpremises and one's personal assumptions about how the world works (J.A. Joh nso n, Germer, Efran, & Overton, 1988; Poznanski & Mc Lennan ,2003; Schacht & Black, 1985). Thus, und erstand ing you r ow n assum ptiveworldview is the starting point for adopting a theory of psychotherapythat is the best fit for you (Drapela, 1990).

On the basis of a review of the many different ways that psychotherapists ' theoretical orientations have been measured, Poznanski andMcLennan (1995) concluded that a two-dimensional model best captures their underlying beliefs: analytic versus experiential and objectiveversus subjective. By incorporating these two dimensions into a four-celled conceptual model, each of the major systems of psychotherapycan be re l iab ly map ped onto on e of the qu ad ran ts (P oznan ski &McLennan, 1995, 1999; Sandell et al., 2004), as depicted in Figure 1.2.By organizing theories in this way, we can generate a conceptualprofile of similarities and differences among thema "periodic table ofthe psychotherapies," if you will. As we do so, we can see more clearlywhat R. B. Miller (1992) described as models of the nature of psychological realityor assumptive worldviewson which each of them is based.In fact, we can see how the different systems of psychotherapy reflectthe most important at tempts in Western phi losophy to understand thenature of reality. Is i t any wonder, then, that there is such debate aboutwhich system of psychotherapy is the right one? Philosophers have been


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F I G U R E 1 . 2Analytic

Objective

BehavioralCognitive Constructivist

Existential Subjective

ExperientialTaxonomy of the systems of psychotherapy.

debating for centuries how reality can be truly known, and they havenot reached a consensus about which worldview is the correct one. Eachof these philosophical worldviews is valid up to a point, and each has itslimitations (B evan, 1991 ; Rychlak, 2 000 ). The strengths of each addressthe weaknesses of the others, without quite managing to completely explain the hu m an condit ion. It m ay just be that our merely m ortal mindsare incapable of grasping the cosmos"A hand cannot grasp itself," asthe Buddhists say. However, take heart: Remember that to the best ofour knowledge with respect to effective psychotherapy, i t doesn't matterthat no system is the "correct" one. It matters that we adopt a theory ofpractice in w hich w e believe, and th e we ll-hon ed w orldviews of history'sgreatest philosophies serve as terrific starting points in our quest. Theworldviews are empiricism, rationalism, humanism, and collectivism.

Empiricism values rational thought applied to objective experienceand is the worldview underlying what is traditionally referred to as sdence. The empirical wo rldview as sum es that people are reactive and separate fromyet determined bytheir environments. Human behavior is


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Adop ting a Theory 11

the result of learning and the product of situation-specific forces. Although life is seen as having many obstacles and struggles, there is always a light at the end of the tunnel; problems can be solved throughdirect action. People are seen as having conflicts with difficult situationsin which they find themselves. Problems in life are the result of currentexternal situations or learned habits that can be mastered through theappropriate application of technique or technology. Emotional responsesto irrational thou gh ts are eliminated or at least controlled by substitutingrational thoughts. Psychotherapies based on empiricism use carefullyselected strategies deliberately applied to specific problems to achieveconcrete, m easura ble outcom es. Each client is appro ached as a case studyor an exp erim ent of N = 1, w he re hypo theses are tested and ne w onesare generated in light of the results. Prediction and control are valued.The results of other l ike-minded therapists and researchers are valuedand applied, if appropriate, to one's own situation. Adopting strategiesand undertaking activities that have been proven effective are encouraged. The therapist's role is one of technical consultation and instruction.The therapist approaches problems with a sense of optimism and a "cando" spirit . Therapeutic instruction in the form of rational thinking oradaptive behaviors is designed to modify clients' cognitions and actionsto bring the m m ore in line w ith the d em ands of reality. Pragm atism is theorder of the day, with improved role functioning (e.g., parent, spouse,breadwinner) and coping skills as goals.

Rationalism values rational thought applied to subjective experience.The rationalistic worldview assumes that only by first understandingourselves can people truly understand the world around us. Participation in the intellectual and emotional process of self-reflection is the meansby which one achieves greater self-understanding. Patterns of our deepest levels of subjective and emotional processes and influences of thepast on the present can be discovered and understood. As our understanding of ourselves changes, we are better able to make rational decisions. Personal imperfections are accepted as inevitable expressions ofone's humanness and as a basis for self-improvement. In the rationalistworldview, human possibility is limited. Indeed, a certain degree of resignation is considered healthy. Honest self-perception and freedom fromillusion are the goalsto reconcile the ideal with what is possible. InFreud's famous words, the best that one can hope for is to exchange"irrat ional misery for com m on unha ppines s" (B reuer & Freud, 1895/1955, p. 305). The limitations of life are accepted; not all is possible, notall is red eem able , no t all poten tialities are realizable. N othing c an be do neto undo the tragic or traumatic facts of one's life. The clock cannot beturn ed back, death cannot be avoided, and hum an natu re cann ot be perfected. The client and the therapist engage in a search for patterns andprocesses in the understanding of old meanings and then create ones


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tha t are more logical. An introspective, subjective, skeptical stance onthe part of the client and therapist is called for, with the therapist encouraging a thoroughgoing internal focus. The therapist aids the client in theexpression of feelings and thoughts a round key influential understandings, e n c o u r a g i n g a de ta i l ed desc r ip t i on of e v e n t s and ref lec t ingempathically on w h a t is said. The therapist identifies with the client'sproblems and personal failings through the human abi l i ty to resonatewith similar tragedies in our own lives.

Humanism values growth-promoting subjective experience. The humanistic worldview assumes that people are intrinsically motivated toward development , growth, and socially constructive behavior. Problemsarise w he n this intrinsic motivation is thwarted or usurped. P roblems areunders tood as developmental challenges that are typically accompaniedby emotional disequilibrium. Rather than being viewed as deficits to beremedied, problems are seen as being powerful opportuni t ies for theemergence of a more evolved self. People are unders tood to be fundamentally active, complex, purposive, autonomous, and creative individuals. Life is seen as having fulfilling and adv entu rou s possibili ties and is tobe lived in the present moment . Individual i ty is idealized and natural .Everyone has a creative spark that can be nurtured th rough the p r o m o tion of free, uninhibited, and aut hen tic self-expression. Risk taking, thepursui t of a unique lifestyle, and the continuous search for self-actualization are the goals of humanism. Empathic contact between the therapist and the client fosters self-acceptance, self-understanding, and growthtoward a fully functioning self. A therapeut ic relationship of unwaver ingacceptance, rather than action or explanation, is the focus of therapy. Itallows clients to fully integrate all aspects of their true selves. Emotionalexperience has a functional role in facilitating change and is thus encouraged. Feelings are seen as safe, even when painful, and they warran t being fully exp erienced to bring rich meanings to life. With personalgrow th comes increased capacity for achieving creative solutions and newforms of knowledge. People can become vibrant, socially engaged, andartistically express ive. A satisfying life is gained by finding an overarchingpurpose and direction that includes values centered on being more attuned, sensitive, and responsive to others. Strengths and talents are assets and gifts to be appreciated and used in the service of others.

Collectivism values growth-promoting objective experiences with others and is the dominant worldview of most non-Western cul tures. Themetaphor of complex, integrated, organic processes that "grow" towardhea lthy functioning is central to collectivism. The collectivistic wo rldviewassumes that social context is what gives life meaning and purpose andthat people and groups are active, purposeful, autonomous, creative, andintegrated into a social m atrix and inherently strive toward healthy functioning. Individuals cannot be unders tood independent of interpersonal


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Adopting a Theory 13

influences, and personal problems are best solved if we involve others inthe solution. Individuals and systems have reciprocal influences on eachother such that changes to social systems bring about changes to individuals and vice versa. Change in one com pone nt of the system wh etherwithin the individual or within the larger social systemwill produce achange elsewhere in the system. Problems in living are seen as by-products of systemic malfunction an d are thus considered indicators that som ething needs to be addressed in the way the system is functioning. Although ou tcomes a re no t comple t e ly p red i c t ab l e , sy s t ems have apropensity for self-regulation such that liberation of any aspect of thesystem will tend to produce an increased capacity for generating creativesolutions. Change is thus not a cumulative event, but i t is a transformative process. Changes to structures bring abo ut changes to individuals byway of changing their relationship to others within the system. Therapists wor king from a collectivist perspective ta ke a n active role in directing changes to systems, and clients are expected to be actively involved.A good fit between individual and system is sought in order to achievestrong interpersonal t ies and multisided, nurturing relationships. Unhealthy social roles, such as sexist and racist stereotypes, are challengedand replaced with egalitarian ones. Communioncontact, openness, andnoncontractual cooperation between personsis seen as the ideal state.

Adopting a Theoryfor PracticeOnce a preferred assum ptive w orldview has be en identified, i t is possibleto proceed to narrowing down choices to a psychotherapeutic system,then to theory, and in some cases, to a particular theorist (Hansen &Freimuth, 1997). A system of therapy, also so m etim es referred to as a schoolor paradigm (Cottone, 1992), represents the appl icat ion of a givenassumpt ive worldv iew to psychotherapeut ic p rac t ice . Because i t i sso closely linked to assumptive worldview, the system level cannot bevalidatedor invalidatedby evidence. This is because the natu re of wh atconstitutes evidence is defined by the epistemological assumptions underlying each system (Boha rt, O'Hara, & Leitner, 19 98; Messer, 1985 ;R. B. Miller, 1992 ). Som eone w ho believes that kn ow ledge is subjective,for example, will not be convinced by empirical data that knowledge isobjective. Similarly, qualitative data cannot proveor disprovethatknowledge is best gained through objective means. Thus, a particulartheory of psychotherapy will feel right if it captures the essence of yourway of making sense of the human experience (Freimuth, 1992; Guy,


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1987; Vasco et al., 1993). Although some will find your preferred theorysimilarly compelling, others will not, because their worldview is differentfrom yours.

Systems of therapy should be categorized on the basis of commonal i ties and differences among their underlying assumptions. Thenum ber ofdifferent schools that various authors have identified depends on thespecificity of beliefs used to discriminate amo ng the m (Hansen & Freimuth,1997). Using the t axonomy of assumptive worldviews presented in Figu re 1.2, four major systems of psychotherapy are identified:

1. Empiricism - Cognitive-Behavioral2. Rationalism > Psychodynamic3. Humanism > Humanist ic4. Collectivism -> Systemic

This level of analysis allows for a bridging from assumptive worldview totheory.Theory gives con tent and a sharp er focus to the assumptive worldviewof a system (Hansen & Fre imu th, 1997). Each system is represented by a

n u m b e r of theories that share assumptions about the na tu re of knowl edge and what counts as evidence, w hile disagreeing on the relative importance or usefulness of key facts. Different theories also prescribe different actions to take in pursui t of goals consistent w ith their assum ptions(Blocher, 1987). Thus, for example, there are psychodynamic theoriesthat emphasize the primacy of the self, or instinctual drives, or internalized relationships (Pine, 1990). Similarly, there are different theorieswithin each of the other systems.

Finally, within each theory there are usually a variety of theoristswho differ in their emphasis or presentat ion of a theory 's governing principles. They also often differ in their personal and writing style such thatmost practit ioners find one or another theorist within a theoretical orien ta t ion m ore to their l iking, perhaps even a theoretical "kindred spirit"(Hansen & Freim uth, 1997).

Putting Theory Into PracticeOnce you have found a theory tha t is a good fit with your assumpt ivewor ldv iewand is t hus one you can believeit is t ime to put it intopractice, that is, to begin to unders t and how to help people who seekyour services. Taking our mode l of psychotherapy presented earl ier inthis chapter, readers can th ink of psychotherapy as the therapist proposing therapeutic tasks designed to facilitate change processes in order to


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T A B L E 1 . 1Theory In to Prac t iceTheory Task Change process Goa lPsychoanalytic Free assoc iationBehavioralPerson-centered

Systemic

Exposure to fearedstimulusExpress negativefeelings in anonjudgmentalcontextReframe anxiety asexcitement

ConsciousnessraisingCounter-condit ioningTolerance fornegativefeelingsNew interpersonalpatterns

Self-understandingDecrease anx ietySelf-acceptance

Anxiety no longera problem

achieve goals. To maximize the likelihood of success, the tasks, changeprocesses, and goals shou ld be believable to the client and the thera pist.The therapist 's job is then to develop a theoret ical ly derived conceptualization of the client's goals and propose tasks consistent with thatconceptualization. All theories have such working hypotheses as a way oftranslating theo ry into practice (Goldfried, 1980). An exa m ple of the application of psychoanalytic, behavioral, person-centered, and systemic theories, respectively, to the treatment of anxiety is presented in Table 1.1.

The following chapters cover nine different th eories of psycho therap y:psychodynamic, behavioral, existential, person-centered, gestalt , cognitive, systemic, feminist, and constructivist. I encourage readers to striveto appreciate the value of each of these theories and the assumptiveworldview on which each rests. Even if a particular theory does not sitwell with youand some likely will notremember that many of theclients who seek your services will have worldviews different from yours(Lyddon, 1989a; Lyddon & Adam son, 1992). The ability to u nd ersta ndand value different worldviews and their concomitant psychotherapeutic goals, cha nge proce sses, and tasks will help you to be mo re effectivewith more people more often.

The Novice PsychotherapistAmanda discovered her interest in psychotherapy during he rundergraduate psychology classes. She found that whenever shelearned something new about psychology she wanted to know how toapply it to helping people. While she was volunteering at a residentialtreatment center, she noticed that those who were able to articulatewhy they w ere in treatment seemed to gain more from it. Therefore,for a class project, she researched how people make meaning of theircircumstances. She discovered Victor Frankl's (1946/1963) Man'sSearch for Meaning: An Introduction to Logotherapy, and "everything fell


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into place" for her. She found reading Frankl a profoundly movingexperience that gave her "the chills" and further deepened her interestin psychotherapy.A defining moment occurred while Amanda was assisting a patientwho was multiply handicapped, severely disfigured, and unable tocommunicate verbally. Using a keypad, the patient tapped outletterby painful letter"Look at me. I am a freak." Amanda looked at her.She looked into her eyes, felt a powerful human connection, and theywept silently together. Amanda experienced an intense helplessnessand wished to know what to say or do to help. She decided to pursuegraduate studies in professional psychology to learn.When Amanda got to graduate school, she was very eager to learnho w to be an effective therap ist. She kept a jou rna l of her expe riencewith the intention of documenting her progress. After 2 years,however, her journal contained only disjointedalbeit helpfulsnippets of clinical wisdom gleaned from instructors, supe rvisors, andclassmates. In therapy, she felt anxious, self-conscious, and unsure ofherself. Something was missing for her.

Then her mother cal led one evening concerned about herbrother's "extreme" reaction to the death of his pet. She askedAmanda why he was behaving so "illogically." Without stopping tothink, Am anda v enture d that his react ion ma y have been an effort tomake meaning of the meaninglessness of death. With this, she realizedthat she made sense of the world through existentialism, and shethrew herself into the writings of the existential therapists with arenewed enthusiasm. She found Irvin Yalom's (2002) approach andwritings to be particularly amenable, and she even waited for hours ata c onfere nce to ha ve him sign a copy of The Gift of Therapy: An OpenLetter to a New Generation of Therapists and Their Patients. S he elo qu en tlydescribed her approach as she entered doctoral school as "joiningclients in their experience and being a supportive witness to theirconfrontation with issues of death, freedom, and isolation so that theycan create meaning in a way that best fits their personal experience."

Learning TaskN o w t h a t y o u h a v e b e e n i n t r o d u c e d t o h o w u n d e r s t a n d i n g w o r l d v i e w sis fun da m en ta l t o be com ing a n e f fec ti ve psyc ho th erap i s t , i t is t im e toiden t i fy your per sona l wor ldv i ew by comple t i ng t he t ask i n Exh ib i t 1 .1 .On ce yo u hav e don e so , t r ans fer yo ur r a t i ngs f rom th e ca t egor i es i n Exhib i t 1 .1 to the corresponding axes of Figure 1 .3 . The in tersect ion of thetw o axes r ep rese n t s 0 , an d the i n t e r sec t i on o f t h e ax i s w i th t he ou t e rc i r c l e r ep resen t s 4 . Connec t t he fou r po in t s , mak ing a rough ly c i r cu l a rs h ap e . T h e t h eo r i e s w i t h i n t h e a r ea o f t h e s e f o u r p o i n t s r ep r e s en t t h o s et h a t a r e m o s t co m p a t i b l e w i t h y o u r p e r s o n a l w o r l d v i ew .

I f you f i nd t ha t you have r a t ed a l l o f t he wor ldv i ews equa l ly , youcou ld t ry us ing a fo rced -cho ice r a t i ng i n wh ich you choose one over t heo ther i n each poss ib l e pa i r i ng : ob j ec t i ve ver sus ana ly t i c , ob j ec t i ve ver sus


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s x w m T 1, 1I den t i f y ing Your Persona l Wor ldv iewTake your time while you carefully read each of the fo l lowing fourdescriptions and rate the degree to which it describes you r beliefs:Ob The w or ld can best be understood by identifying the characteristics ofphenom ena th a t represent a stable und erlying essence. The bestapproach to understanding the w orl d is by gathering measurementstha t are publicly confirma ble. A complete e xplanation is one in whichthe comm on features tha t account for the funct ioning of aphe nom eno n have been classified.

Not at a ll 0 1 2 3 4 CompletelyA n The w orl d can best be understood by discovering the action of

phenomena onone a nother. The best approach to understanding thew or ld is thr ou gh logical analysis th a t enables us to achieve grea terdegrees of appreciation of the laws of nature. An explanation iscomplete w hen the causes of a phenomenon have been ident i f ied.N o t at a ll 0 1 2 3 4 Completely

Su The wo rld can best be understood by the person tryin g to understandit . The best approach to understanding the wo rld is throu ghintrospection tha t culminates in a highly personal result. A completeexplanation is a rich, comprehensible description of an experience.N ot at a ll 0 1 2 3 4 CompletelyEx The wo rld is best unde rstood as being driven by developmentalprocesses to w ar d healthy fu nc tio nin g. The best approach tounderstanding the world is to participate without preconceivedno tions so th a t these processes can be appreciated. An explanation iscomplete w hen the processes and u ltim ate fu nc tion of a phenomenonhave been described.Not at a ll 0 1 2 3 4 Completely

Now transfer your ratings to the fo l low ing categories:Ob = ObjectiveAn = AnalyticSu = SubjectiveEx = Experiential

subjective, objective versus experiential, analytic versus subjective, analytic versus experiential, and subjective versus experiential. Once youhave done so, add the number of times you chose each one. Transferthese numbers to the corresponding axes of Figure 1.3.

If you still find that you are having difficulty, you could try rereadingthe more detailed description of each worldview on pages 10-13, pausing to reflect on each, and then letting your intuition guide you. One


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F I G U R E 1 . 3Analytic

Objective Subjective

ExperientialPlotting your psychotherapeutic worldview.

way to do this might be to flip a coin and, before you look at the result,notice whether you are hoping for a particular result . (You may havenoticed that your preference for a particular type of evidence is also aclue as to your personal worldview.)It is not vitally important that you identify the one theory that isright for you. In fact, many therapists find a number of theories amenable. It is m ost im porta nt that y ou avoid practicing from a theo ry b asedon a worldview incompatible with your own. As long as you begin witha compatible theory, you will put yourself on track for a long, satisfying,and effective career during which you will very likely explore many different theories as you develop your personal approach to psychotherapy(as discussed in chap. 11).

Your Reflective Jou rna lAt the end of each chapter you will be invited to add to your own personal reflective journal. The intent is to challenge you to think about


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your individual perspective on the strengths and weaknesses of eachapproach. Consolidating what might work best for you is a crucial aspectof your development as a psychotherapist. To choose a particular therapeutic orientation requires thorough and deep processing of the information presented in this volume. Writing is a particularly good way toaccom plish this processing. S ome m ay find wr iting to be ra the r difficultor unappealing, however, and may prefer to create an audio or videojournal, for example. Whatever you choose, I encourage you to find away that works for you. You might also want to keep a pen and paper orother recording device available while you are reading each chapter sothat you can record your thoughts and impressions while they are fresh.Im m ediate reactions can be a good source of inform ation abou t yourself,and therefore you m ay w ant to record the m before they are lost. You willlater be asked to reflect on what you found appealing about each approach, what you identified with, what you found difficult to accept, andany unanswered quest ions you may have.

For this first chapter, begin your journal by recording an autobiographical sketch of how you came to pursue psychotherapy as your career. Think about the turning points in your career as a psychotherapistto date, even if you see yourself as "just a student." What have been thepivotal events that occurred in you r life as you becam e a therapist? W hatimportant choices have you made? For example, when did you decidethat you wanted to become a therapist? What ideas did you have aboutw ha t a therapist is and does? How did you come to form th ese ideas? Youmight want to consider some of the influences on your choice. Werethey familial, personal, or something else? You may also choose to consider some of your formative experiences as a therapist. What is mostsalient about these experiences for you? Were they your own experiences, someone else's experiences, a persuasive argument, compellingdata? Do the content and nature of these influences and experiencesinform you about your personal worldview? Take some time to writedown your responses to these and any other questions that occur to you.

SummaryFor psychotherapy to be effective, a client must seek help from a therapist w ho he or she believes to be com petent, the client m ust e xperience acollaborative relationship with the therapist, the treatment must have aplausible therapeutic rationale that is believable to the therapist and client, and it must involve activities and goals consistent with the rationale.On the basis of the available, overw helm ing researc h evidence, no theor yof psychotherapy has been found to be superior to another. Rather, what


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is im porta nt is that the practit ioner and the client believe in the thera py.A theo ry provides a framew ork for (a) generating hyp otheses ab out w hatchange processes will further client goals, (b) formulating tasks to facilitate desired change processes, and (c) evaluating progress toward thosegoals. Finding a theory in which you can believe involves identifyingyour assumptive worldview about the nature of the world from amongfour alternatives: empiricism, rationalism, humanism, and collectivism.Once you r persona l assum ptive w orldview h as been identified, it is possible to proceed to narrowing down your choices to psychotherapeuticsystem, theory, and theorist through in-depth study of existing, well-developed theories.

Further ResourcesFreed heim, D. K. (Ed .). (1992 ). History of psychotherapy: A century of change.

W ashington, DC: A merican Psychological A ssociation.Hubble, M. A., Dun can, B. L., & Miller, S. D. (Eds.). (1999 ). The heart and soul

of change: What works in therapy. W ashing ton, DC: Am erican PsychologicalAssociation.

Lambert, M. J. (Ed .). (2004) . Bergin and Garfield's handbook of psychotherapyand behavior change (5th ed.). New York: Wiley.Snyder, C. R., & Ing ram , R. E. (Eds.). (2000 ). Handbook of psychological change:Psychotherapy processes and practices for the 21st century. New York: Wiley.Wampold, B. E. (2001). The great psychotherapy debate: Models, methods, andfind-

ings. Mahw ah, NJ: Erlbaum.

1-adopting a theory

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