Br. .I. med. Psychol. (1977). 50, 361-365
Printed in Great Britain
36 1
Psychotherapy: Theory, experience, and personalized actuarial tables Donald B. Leventhal and Kenneth M. Shemberg This paper addresses the issue of the role of theory in the actual application of psychotherapeutic operations. Within the present framework, psychotherapeutic effectiveness is seen as an empirical, actuarial process which occurs in an interpersonal setting separate from theoretical considerations. The role of theory is discussed and a rationale for the coexistence of equally ‘effective’ contradictory theories is presented. Suggestions for future research in the area of behaviour change are made and an argument for the eventual development of a ‘therapeutic cookbook’ is presented. It appears from the limited research and clinical evidence available that psychotherapeutic approaches with vastly different theoretical foundations are of equal value in the treatment of psychological disorders. This state of affairs is reflected in the way we often teach. Our didactic graduate courses in psychotherapy are frequently comprised of reviews of the major theoretical systems which detail how advocates of Freud, Ellis, Rogers, Wolpe, etc., differentially interpret and conceptualize similar patient behaviours. Students often ask the obvious question, ‘How can they all be right?’ A partial answer was provided by Fiedler (1950), i.e. psychotherapy is effective to the extent that the therapist is experienced regardless of his theoretical orientation. While this reply strikes us as basically correct, the process by which therapists’ experiences mediate therapeutic change in patients is unspecified. Therefore, the purpose of the present paper is to outline how we believe therapist experience mediates behaviour change in patients and to provide a rationale for the coexistence of contradictory theories which appear equally effective with similar patient problems. In order to clarify what we believe actually occurs, we have outlined our interpretation of the therapeutic process in the following oversimplified way: 1. Therapists enter treatment relationships with a theoretical system which includes: (a) some form of basic personality theory including beliefs regarding the aetiology of aberrant behaviour; (6) some beliefs relative to what needs to be changed in the patient to ameliorate the disturbance; and ( c ) beliefs about behaviours the therapist should engage in so that desired patient changes will be facilitated. 2. From this theoretical stance, therapists observe the patients’ behaviour (i.e. perform ‘assessment’) and as a function of this process, they believe that they are guided to engage in specific therapeutic operations. Thus, observed behaviour is conceptualized within the context of a particular theory and therapists believe that they derive therapeutic operations from the theory as the treatment approach is developed. 3. As treatment is carried out over time, therapists apply their operations, i.e. they engage in behaviour vis-b-vis the patient which they believe will produce desired changes. These three steps describe in general the overall process in initiating and carrying out psychotherapy. However, this overview does not specify how therapists’ experience mediates what is done and what outcomes occur. We believe that as patients’ behaviour changes the therapist observes and stores empirical relationships between specific patient behaviours and specific therapist behaviours. Depending upon the desirability of patient changes, operations regarding specific therapist behaviours are either strengthened or weakened. Those that are strengthened have a high probability of being utilized in the future given similar patient behaviours. Those that are weakened have a lower probability of being engaged in with other patient problems. We believe that it is this step that is critical in terms of therapeutic activities,
362 Donald B. Leventhal and Kenneth M . Shemberg i.e. over time and with a variety of patients, therapists learn that, given patient behaviour A, therapist behaviour B will probably produce patient response C, and as a function of the above, therapists develop personalized actuarial tables. These tables provide gross probability estimates of outcomes given certain patient behaviours and certain therapist responses. Thus, we believe that what appear to be deductively derived, conceptually consistent therapeutic operations are nothing more and nothing less than inductively derived empirical relationships. Obviously, one implication of this process is that, in general, as a therapist gains experience (i.e. sees more patients over a longer and longer period of time), his experience tables become more complete and, in addition, more reliable. Thus, we are proposing that a therapist’s effectiveness is in large part due to the completeness and reliability of his personalized actuarial tables. ‘ This whole issue becomes clouded by the fact that workers rarely specify their therapeutic activities in terms of empirical operations and outcomes. In fact, it might be argued that these processes are not verbalizable. We maintain that this is not the case, but rather that our preoccupation with theoretical systems determines that we employ the language of constructs rather than the language or empirical operations to describe what we do. Furthermore, we believe that it is possible to describe very complicated therapeutic activity in empirical terms if we train ourselves to do so. In fact, it is extremely common in clinical conferences or patient staffings for us all to answer questions about treatment decisions and operations with the preface, ‘In my experience with people like this. . . ’. This statement often preceeds an empirical conception of behaviour and is rarely the introduction to a theoretical discussion. We believe the above discussion approaches an answer to the question of how therapist experience mediates behaviour change. However, it does not deal directly with our second question, i.e. how can contradictory theories which appear to produce equally effective operations with similar patients coexist? A fundamental premise to our argument is that various theories of psychotherapy are, in fact, complex belief systems which by their very nature are incapable of falsification. That is, our theories are constructed in such a way that, in a post-dictive manner, all empirical outcomes (either success or failure) can be integrated and described within any of these conceptual systems. Thus, after the fact, any outcome can be construed as ‘evidence ’ for the validity of the theory. There is another aspect to this problem. That is, to the extent that we are emeshed in a particular theoretical orientation, we do not seek disconfirmatory evidence even if it were possible to obtain. It is our argument that this state of affairs promotes and perpetuates the coexistence of contradictory theoretical systems. In a sense, the situation is not unlike the coexistence of a variety of contradictory religious systems. That is, religious beliefs are stated in ways which preclude falsification. Also, advocates of any given religion fail or often refuse to seek disconfirmation. Given all that has been said, it is clear that we are conceptualizing the therapeutic process within the framework of actuarial logic. This conception might be considered as advocating the notion that psychotherapy can be carried out in a cold, empirical, mechanistic fashion. While this may be true, we do not believe that one can remove ‘the human element ’. Even though we are proposing that the critical ingredients in psychotherapy are derived from an actuarial, empirical process, we also believe that effective psychotherapy must include a meaningful, interpersonal relationship between patient and therapist. Almost universally, theorists concerning themselves with the therapy process devote considerable space to the necessity for providing this atmosphere (e.g. Rogers, 1951; Sullivan, 1954; Freud, 1959; Ginott, 1961; Bandura, 1969; Arieti, 1973). If it is true that the therapy process is based upon personalized actuarial tables of the therapist as these tables are utilized within an appropriate interpersonal relationship, then one must raise the question: Why theories of therapy? Why have so many years been devoted to the development of elaborate ‘explanatory ’ systems which may do nothing more than provide for
Psychotherapy: Theory and experience 363 post hoc descriptions of empirical events? This question could be approached from the point of view of the philosophy of science. That is, one could make all the arguments about the nature and value of theory as it relates to the understanding of any set of natural events. However, as has frequently been stated (Thorne, 1972), our field is at this time in a ‘pre-scientific phase’ where our theorizing is far beyond our empirical evidence. Thus, ‘a major source of clinical error has resulted from uncritical attempts to apply theoretical psychopathology in terms of diagnostic or therapeutic decisions, which turn out to be unreliable or invalid’ (Thorne, 1972, p. 36). Given this state of affairs, there is at least one other answer to the question, ‘Why theories of therapy? ’ Many philosophers, theologians, and psychologists have discussed the human condition as including man’s basic ‘need to know’. That is, as Allport has stated, ‘We have to simplify in order to live; we need stability in our perceptions. At the same time, we have an insatiable hunger for explanations. We like nothing left dangling; everything should have a place in the scheme of things. Even the young child asks, “Why, why, why?”’ (Allport, 1954, p. 170). At least in part, theories of therapy may represent ways in which therapists dealing with complex, confusing material deal with their own need to know. Perhaps this can best be illustrated by a vignette from the author’s own experience. A few years ago, Austin DesLauriers visited our department. He was discussing his differential theories regarding the development of childhood autism versus childhood schizophrenia. He was also exemplifying his specific treatment operations for each of these disorders. At one point, he described a particular operation in treating a schizophrenic child exhibiting a particular behaviour and provided a theoretical rationale for that operation. He later described an identical therapeutic operation which he applied to an autistic child, who exhibited a highly similar behaviour. At that point, he provided a totally different theoretical rationale. It was pointed out to him that the treatment operation was essentially the same for the two children and that it was applied in response to similar patient behaviours. He was then asked what purposes do the two different theoretical systems have if his therapy response was actually determined by the children’s behaviour regardless of the diagnosis. DesLauriers answered in essence: ‘I need to know why I am doing what I am doing’. From our viewpoint, DesLauriers’ long experience with autistic and schizophrenic children has provided him with massive experience tables regarding responses he should make to specific patient behaviours. It is our belief that these experiencedetermined tables mediate his therapeutic operations and that the conceptual interpretation of the operations and the outcomes represent post hoc explanations which are unnecessary from the point of view of engaging in effective psychotherapy with these children. Given the above considerations, a question related to ‘Why theory?’ is ‘Does theory have any utility at all?’ We believe that the answer to this question is a qualified yes. If we consider the theories as overall frameworks within which behaviour can be viewed, rather than conceptual schemes which lead to specifiable operations with predictable outcomes, these frameworks do provide therapists with something. For example, in training the beginning therapist, it becomes highly important to the trainee for supervisors to provide some overall unifying scheme which at least on the surface appears to make sense out of the complexity of his patient’s behaviour. This scheme seemingly adds credibility to the therapeutic operations and also satisfies the student’s ‘need to know’. We have noted that students become very anxious in supervision when the only answer to their question, ‘Why should I do that?’ is ‘In my experience with this kind of patient, if you do this, it will probably work’. Almost inevitably the student again asks, ‘Why?’. This discomfort is likely to lead the supervisor to rely upon the authority of conceptual schemes. Thus, one can view theoretical frameworks as, in part, providing therapists with a set of security operations. These security operations are likely to be most important in the early stages of the therapist’s development prior to his acquiring broad personalized experience tables. Over time, it is our belief that the importance of the theoretical framework diminishes, even though therapists generally fail to recognize this and continue to couch descriptions of their operations within the
364 Donald B. Leventhal and Kenneth M . Shemberg
framework of their own theoretical systems. Wolberg (1974) has recognized a similar point in stating ‘It is my conviction that every good therapist must eventually break the chrysalis of his training experience and modulate his orthodox methods with interventions he evolves out of his own experience’ (p. 9). There is another side to the utility of theory which is highly practical in nature. Theories provide some basis for communication among therapists in that they form relatively common language systems. Unfortunately, the full value of this aspect of theory is not attained due to the diversity of conceptual systems, and the lack of precision of terms within and among systems which often inhibits good communication. An additional value of a conceptual system is the potential therapeutic benefit patients might derive from adopting their own view of the therapist’s framework. In other words, conceptual systems may have some impact on behavioural change by satisfying the patient’s ‘need to know’ and by making it easier for the patient to accept therapeutic operations as ‘sensible’. Given the limited value of conceptual systems, one must raise the question ‘Will continuing to rely upon theoretical systems provide a truly scientifically based conceptualization of psychotherapy?’ Many believe not (Bergin & Strupp, 1970; Lazarus, 1971; London, 1972; Mosher, 1972). These authors have all expressed dissatisfaction with theoretical conceptions of psychotherapy and have argued that these approaches will not lead to a productive technology. Thus, there is an increasing call for systematic research which specifies relationships among ( a ) specific patient behaviours; (6) specific therapist behaviours; and (c) specific outcomes. One research strategy which may provide some needed data is the ideographic clinical case study. But rather than viewing our cases theoretically, we should attempt to specify, in observable terms, therapist and patient behaviours. Such research, if continually replicated over time and over therapists and patients, may eventually provide us with explicit probability statements concerning the relationship among these variables. This argument can be stated much as Meehl (1956) stated his position in regard to diagnosis, i.e. Wanted: A good cookbook. Perhaps such a ‘cookbook’ might satisfy our ‘need to know’. In any event, such prescriptive tables could eliminate one major source of errors in judgement. That is, our personalized actuarial tables are highly fallible since our own storage capacity is limited. The partial reduction of the therapeutic process to the application of actuarial tables is difficult to accept, even for the authors. However, such tables function very well in some areas of medicine where, for example, the application of a particular drug therapy ameliorates a particular pathological condition in the absence of total understanding of the biochemical functioning of the drug. We do not mean to imply that the development of a highly inclusive ‘cookbook’ will mean that all therapists will be able to engage in all appropriate operations with all patients. Psychotherapy will still be an interpersonal process. Hopefully, through their experience, therapists will be able to know more explicitly which operations they can engage in and thus which patient behaviours they can treat effectively. An additional concluding note is necessary. It can be argued that the call for empirically categorizing and classifying therapist and patient behaviours is in reality a call for theory in a different disguise. We can not deny that such classification can be defined as ‘theoretical’. We believe, however, that theory at this level is fundamentally different from the highly complex hypothetical-deductive belief systems which are currently considered theories of therapy. To the extent that the actuarial classification of empirical events represents theory at all, it is theory that is certainly ‘close to the data’. It is clearly not beyond the realm of possibility that, once these empirically based classifications are well established, a more comprehensive and higher level theory of therapy may emerge. However, it seems clear that this development is far in the future.
Psychotherapy: Theory and experience 365 References ALLPORT, G. (1954). The Nature of Prejudice. Boston: Beacon Press. ARIETI,S. (1973). Individual psychotherapy of schizophrenia. In S . Arieti (ed.),American Handbook of Psychiatry, 2nd ed., vol. 111, pp. 627-651. New York: Basic Books. BANDURA, A. (1969). Principles of Behavior Modification. New York: Holt, Rinehart & Winston. H.(1970). New directions in BERGIN,A. & STRUPP. psychotherapy research. J. abnonn. Psychol. 76, 13-26.
FIEDLER, F. (1950). A comparison of therapeutic relationships in psycho-analytic, nondirective, and Adlerian therapy. J. consult. Psychol. 14.43-5. FREUD, S . (1959). Recommendations for physicians on the psychoanalytic method of treatment. In S . Freud, Collected Papers, vol. 11. New York: Basic Books. GINOTT, H. (l%l), Group Psychotherapy with Children. New York: McGraw-Hill.
LAZARUS,A. (1971). Behavior Therapy and Beyond. New York: McGraw-Hill. LONDON,P. (1972). The end of ideology in behavior modification. Am. Psychol. 27, 913-920. MEEHL,P. (1956). Wanted: A good cookbook. Am. Psychol. 11, 263-272. MOSHER,L. (1972). Recent trends in psychosocial treatment of schizophrenia. Am. J. Psychoanal. 32, 9-15.
ROGERS,C. (1951). Client Centered Therapy. Boston: Houghton Mifflin. SULLIVAN, H. (1954). The Psychiatric Interview. New York: Norton. THORNE, F. (1972). Clinical judgement. In R. Woody & J. Woody (eds), Clinical Assessment in Counseling and Psychotherapy. New York: Appleton-Centur y-Crof ts . WOLBERG,L. (1974). Toward a comprehensive psychotherapy. J. Am. Acad. Psychoanal. 2 , 349-360.
Received 16 June 1976 Requests for reprints should be addressed to Professor D. B. Leventhal, Psychology Department, Bowling Green State University, Bowling Green, Ohio 43403, USA. Kenneth M. Shemberg is at the same address.
Printed in Great Britain
36 1
Psychotherapy: Theory, experience, and personalized actuarial tables Donald B. Leventhal and Kenneth M. Shemberg This paper addresses the issue of the role of theory in the actual application of psychotherapeutic operations. Within the present framework, psychotherapeutic effectiveness is seen as an empirical, actuarial process which occurs in an interpersonal setting separate from theoretical considerations. The role of theory is discussed and a rationale for the coexistence of equally ‘effective’ contradictory theories is presented. Suggestions for future research in the area of behaviour change are made and an argument for the eventual development of a ‘therapeutic cookbook’ is presented. It appears from the limited research and clinical evidence available that psychotherapeutic approaches with vastly different theoretical foundations are of equal value in the treatment of psychological disorders. This state of affairs is reflected in the way we often teach. Our didactic graduate courses in psychotherapy are frequently comprised of reviews of the major theoretical systems which detail how advocates of Freud, Ellis, Rogers, Wolpe, etc., differentially interpret and conceptualize similar patient behaviours. Students often ask the obvious question, ‘How can they all be right?’ A partial answer was provided by Fiedler (1950), i.e. psychotherapy is effective to the extent that the therapist is experienced regardless of his theoretical orientation. While this reply strikes us as basically correct, the process by which therapists’ experiences mediate therapeutic change in patients is unspecified. Therefore, the purpose of the present paper is to outline how we believe therapist experience mediates behaviour change in patients and to provide a rationale for the coexistence of contradictory theories which appear equally effective with similar patient problems. In order to clarify what we believe actually occurs, we have outlined our interpretation of the therapeutic process in the following oversimplified way: 1. Therapists enter treatment relationships with a theoretical system which includes: (a) some form of basic personality theory including beliefs regarding the aetiology of aberrant behaviour; (6) some beliefs relative to what needs to be changed in the patient to ameliorate the disturbance; and ( c ) beliefs about behaviours the therapist should engage in so that desired patient changes will be facilitated. 2. From this theoretical stance, therapists observe the patients’ behaviour (i.e. perform ‘assessment’) and as a function of this process, they believe that they are guided to engage in specific therapeutic operations. Thus, observed behaviour is conceptualized within the context of a particular theory and therapists believe that they derive therapeutic operations from the theory as the treatment approach is developed. 3. As treatment is carried out over time, therapists apply their operations, i.e. they engage in behaviour vis-b-vis the patient which they believe will produce desired changes. These three steps describe in general the overall process in initiating and carrying out psychotherapy. However, this overview does not specify how therapists’ experience mediates what is done and what outcomes occur. We believe that as patients’ behaviour changes the therapist observes and stores empirical relationships between specific patient behaviours and specific therapist behaviours. Depending upon the desirability of patient changes, operations regarding specific therapist behaviours are either strengthened or weakened. Those that are strengthened have a high probability of being utilized in the future given similar patient behaviours. Those that are weakened have a lower probability of being engaged in with other patient problems. We believe that it is this step that is critical in terms of therapeutic activities,
362 Donald B. Leventhal and Kenneth M . Shemberg i.e. over time and with a variety of patients, therapists learn that, given patient behaviour A, therapist behaviour B will probably produce patient response C, and as a function of the above, therapists develop personalized actuarial tables. These tables provide gross probability estimates of outcomes given certain patient behaviours and certain therapist responses. Thus, we believe that what appear to be deductively derived, conceptually consistent therapeutic operations are nothing more and nothing less than inductively derived empirical relationships. Obviously, one implication of this process is that, in general, as a therapist gains experience (i.e. sees more patients over a longer and longer period of time), his experience tables become more complete and, in addition, more reliable. Thus, we are proposing that a therapist’s effectiveness is in large part due to the completeness and reliability of his personalized actuarial tables. ‘ This whole issue becomes clouded by the fact that workers rarely specify their therapeutic activities in terms of empirical operations and outcomes. In fact, it might be argued that these processes are not verbalizable. We maintain that this is not the case, but rather that our preoccupation with theoretical systems determines that we employ the language of constructs rather than the language or empirical operations to describe what we do. Furthermore, we believe that it is possible to describe very complicated therapeutic activity in empirical terms if we train ourselves to do so. In fact, it is extremely common in clinical conferences or patient staffings for us all to answer questions about treatment decisions and operations with the preface, ‘In my experience with people like this. . . ’. This statement often preceeds an empirical conception of behaviour and is rarely the introduction to a theoretical discussion. We believe the above discussion approaches an answer to the question of how therapist experience mediates behaviour change. However, it does not deal directly with our second question, i.e. how can contradictory theories which appear to produce equally effective operations with similar patients coexist? A fundamental premise to our argument is that various theories of psychotherapy are, in fact, complex belief systems which by their very nature are incapable of falsification. That is, our theories are constructed in such a way that, in a post-dictive manner, all empirical outcomes (either success or failure) can be integrated and described within any of these conceptual systems. Thus, after the fact, any outcome can be construed as ‘evidence ’ for the validity of the theory. There is another aspect to this problem. That is, to the extent that we are emeshed in a particular theoretical orientation, we do not seek disconfirmatory evidence even if it were possible to obtain. It is our argument that this state of affairs promotes and perpetuates the coexistence of contradictory theoretical systems. In a sense, the situation is not unlike the coexistence of a variety of contradictory religious systems. That is, religious beliefs are stated in ways which preclude falsification. Also, advocates of any given religion fail or often refuse to seek disconfirmation. Given all that has been said, it is clear that we are conceptualizing the therapeutic process within the framework of actuarial logic. This conception might be considered as advocating the notion that psychotherapy can be carried out in a cold, empirical, mechanistic fashion. While this may be true, we do not believe that one can remove ‘the human element ’. Even though we are proposing that the critical ingredients in psychotherapy are derived from an actuarial, empirical process, we also believe that effective psychotherapy must include a meaningful, interpersonal relationship between patient and therapist. Almost universally, theorists concerning themselves with the therapy process devote considerable space to the necessity for providing this atmosphere (e.g. Rogers, 1951; Sullivan, 1954; Freud, 1959; Ginott, 1961; Bandura, 1969; Arieti, 1973). If it is true that the therapy process is based upon personalized actuarial tables of the therapist as these tables are utilized within an appropriate interpersonal relationship, then one must raise the question: Why theories of therapy? Why have so many years been devoted to the development of elaborate ‘explanatory ’ systems which may do nothing more than provide for
Psychotherapy: Theory and experience 363 post hoc descriptions of empirical events? This question could be approached from the point of view of the philosophy of science. That is, one could make all the arguments about the nature and value of theory as it relates to the understanding of any set of natural events. However, as has frequently been stated (Thorne, 1972), our field is at this time in a ‘pre-scientific phase’ where our theorizing is far beyond our empirical evidence. Thus, ‘a major source of clinical error has resulted from uncritical attempts to apply theoretical psychopathology in terms of diagnostic or therapeutic decisions, which turn out to be unreliable or invalid’ (Thorne, 1972, p. 36). Given this state of affairs, there is at least one other answer to the question, ‘Why theories of therapy? ’ Many philosophers, theologians, and psychologists have discussed the human condition as including man’s basic ‘need to know’. That is, as Allport has stated, ‘We have to simplify in order to live; we need stability in our perceptions. At the same time, we have an insatiable hunger for explanations. We like nothing left dangling; everything should have a place in the scheme of things. Even the young child asks, “Why, why, why?”’ (Allport, 1954, p. 170). At least in part, theories of therapy may represent ways in which therapists dealing with complex, confusing material deal with their own need to know. Perhaps this can best be illustrated by a vignette from the author’s own experience. A few years ago, Austin DesLauriers visited our department. He was discussing his differential theories regarding the development of childhood autism versus childhood schizophrenia. He was also exemplifying his specific treatment operations for each of these disorders. At one point, he described a particular operation in treating a schizophrenic child exhibiting a particular behaviour and provided a theoretical rationale for that operation. He later described an identical therapeutic operation which he applied to an autistic child, who exhibited a highly similar behaviour. At that point, he provided a totally different theoretical rationale. It was pointed out to him that the treatment operation was essentially the same for the two children and that it was applied in response to similar patient behaviours. He was then asked what purposes do the two different theoretical systems have if his therapy response was actually determined by the children’s behaviour regardless of the diagnosis. DesLauriers answered in essence: ‘I need to know why I am doing what I am doing’. From our viewpoint, DesLauriers’ long experience with autistic and schizophrenic children has provided him with massive experience tables regarding responses he should make to specific patient behaviours. It is our belief that these experiencedetermined tables mediate his therapeutic operations and that the conceptual interpretation of the operations and the outcomes represent post hoc explanations which are unnecessary from the point of view of engaging in effective psychotherapy with these children. Given the above considerations, a question related to ‘Why theory?’ is ‘Does theory have any utility at all?’ We believe that the answer to this question is a qualified yes. If we consider the theories as overall frameworks within which behaviour can be viewed, rather than conceptual schemes which lead to specifiable operations with predictable outcomes, these frameworks do provide therapists with something. For example, in training the beginning therapist, it becomes highly important to the trainee for supervisors to provide some overall unifying scheme which at least on the surface appears to make sense out of the complexity of his patient’s behaviour. This scheme seemingly adds credibility to the therapeutic operations and also satisfies the student’s ‘need to know’. We have noted that students become very anxious in supervision when the only answer to their question, ‘Why should I do that?’ is ‘In my experience with this kind of patient, if you do this, it will probably work’. Almost inevitably the student again asks, ‘Why?’. This discomfort is likely to lead the supervisor to rely upon the authority of conceptual schemes. Thus, one can view theoretical frameworks as, in part, providing therapists with a set of security operations. These security operations are likely to be most important in the early stages of the therapist’s development prior to his acquiring broad personalized experience tables. Over time, it is our belief that the importance of the theoretical framework diminishes, even though therapists generally fail to recognize this and continue to couch descriptions of their operations within the
364 Donald B. Leventhal and Kenneth M . Shemberg
framework of their own theoretical systems. Wolberg (1974) has recognized a similar point in stating ‘It is my conviction that every good therapist must eventually break the chrysalis of his training experience and modulate his orthodox methods with interventions he evolves out of his own experience’ (p. 9). There is another side to the utility of theory which is highly practical in nature. Theories provide some basis for communication among therapists in that they form relatively common language systems. Unfortunately, the full value of this aspect of theory is not attained due to the diversity of conceptual systems, and the lack of precision of terms within and among systems which often inhibits good communication. An additional value of a conceptual system is the potential therapeutic benefit patients might derive from adopting their own view of the therapist’s framework. In other words, conceptual systems may have some impact on behavioural change by satisfying the patient’s ‘need to know’ and by making it easier for the patient to accept therapeutic operations as ‘sensible’. Given the limited value of conceptual systems, one must raise the question ‘Will continuing to rely upon theoretical systems provide a truly scientifically based conceptualization of psychotherapy?’ Many believe not (Bergin & Strupp, 1970; Lazarus, 1971; London, 1972; Mosher, 1972). These authors have all expressed dissatisfaction with theoretical conceptions of psychotherapy and have argued that these approaches will not lead to a productive technology. Thus, there is an increasing call for systematic research which specifies relationships among ( a ) specific patient behaviours; (6) specific therapist behaviours; and (c) specific outcomes. One research strategy which may provide some needed data is the ideographic clinical case study. But rather than viewing our cases theoretically, we should attempt to specify, in observable terms, therapist and patient behaviours. Such research, if continually replicated over time and over therapists and patients, may eventually provide us with explicit probability statements concerning the relationship among these variables. This argument can be stated much as Meehl (1956) stated his position in regard to diagnosis, i.e. Wanted: A good cookbook. Perhaps such a ‘cookbook’ might satisfy our ‘need to know’. In any event, such prescriptive tables could eliminate one major source of errors in judgement. That is, our personalized actuarial tables are highly fallible since our own storage capacity is limited. The partial reduction of the therapeutic process to the application of actuarial tables is difficult to accept, even for the authors. However, such tables function very well in some areas of medicine where, for example, the application of a particular drug therapy ameliorates a particular pathological condition in the absence of total understanding of the biochemical functioning of the drug. We do not mean to imply that the development of a highly inclusive ‘cookbook’ will mean that all therapists will be able to engage in all appropriate operations with all patients. Psychotherapy will still be an interpersonal process. Hopefully, through their experience, therapists will be able to know more explicitly which operations they can engage in and thus which patient behaviours they can treat effectively. An additional concluding note is necessary. It can be argued that the call for empirically categorizing and classifying therapist and patient behaviours is in reality a call for theory in a different disguise. We can not deny that such classification can be defined as ‘theoretical’. We believe, however, that theory at this level is fundamentally different from the highly complex hypothetical-deductive belief systems which are currently considered theories of therapy. To the extent that the actuarial classification of empirical events represents theory at all, it is theory that is certainly ‘close to the data’. It is clearly not beyond the realm of possibility that, once these empirically based classifications are well established, a more comprehensive and higher level theory of therapy may emerge. However, it seems clear that this development is far in the future.
Psychotherapy: Theory and experience 365 References ALLPORT, G. (1954). The Nature of Prejudice. Boston: Beacon Press. ARIETI,S. (1973). Individual psychotherapy of schizophrenia. In S . Arieti (ed.),American Handbook of Psychiatry, 2nd ed., vol. 111, pp. 627-651. New York: Basic Books. BANDURA, A. (1969). Principles of Behavior Modification. New York: Holt, Rinehart & Winston. H.(1970). New directions in BERGIN,A. & STRUPP. psychotherapy research. J. abnonn. Psychol. 76, 13-26.
FIEDLER, F. (1950). A comparison of therapeutic relationships in psycho-analytic, nondirective, and Adlerian therapy. J. consult. Psychol. 14.43-5. FREUD, S . (1959). Recommendations for physicians on the psychoanalytic method of treatment. In S . Freud, Collected Papers, vol. 11. New York: Basic Books. GINOTT, H. (l%l), Group Psychotherapy with Children. New York: McGraw-Hill.
LAZARUS,A. (1971). Behavior Therapy and Beyond. New York: McGraw-Hill. LONDON,P. (1972). The end of ideology in behavior modification. Am. Psychol. 27, 913-920. MEEHL,P. (1956). Wanted: A good cookbook. Am. Psychol. 11, 263-272. MOSHER,L. (1972). Recent trends in psychosocial treatment of schizophrenia. Am. J. Psychoanal. 32, 9-15.
ROGERS,C. (1951). Client Centered Therapy. Boston: Houghton Mifflin. SULLIVAN, H. (1954). The Psychiatric Interview. New York: Norton. THORNE, F. (1972). Clinical judgement. In R. Woody & J. Woody (eds), Clinical Assessment in Counseling and Psychotherapy. New York: Appleton-Centur y-Crof ts . WOLBERG,L. (1974). Toward a comprehensive psychotherapy. J. Am. Acad. Psychoanal. 2 , 349-360.
Received 16 June 1976 Requests for reprints should be addressed to Professor D. B. Leventhal, Psychology Department, Bowling Green State University, Bowling Green, Ohio 43403, USA. Kenneth M. Shemberg is at the same address.
