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Psychotherapy as Applied Science or Moral Praxis: The Limitations of Empirically Supported Treatment
Kevin R. Smith
Pittsburgh, Pennsylvania Proponents of empirically supported treatment (EST) have argued that psychotherapists have an ethical obligation to make an EST the rst choice in clinical practice. This paper challenges this idea. The EST program assumes a model of therapy as technology or applied science that poorly ts the reality of psychotherapeutic practice. The problems brought to therapy implicate fundamental questions regarding what constitutes a good life. A therapeutic response to such problems is not a technical means to change a circumscribed disorder, but an engagement with the client that has relevance to broader moral concerns. Further, the picture of therapy as technology of change implicitly proposes views of a good life, while not acknowledging that it is doing so. Keywords: empirically supported treatment, ethics, praxis, Aristotle, good life
Does therapy do any good? What good does it do? At which good(s) should it aim? One approach to such fundamental ethical questions is to recast them as questions about whether therapy works to bring about some speciable change in symptoms or behaviors. Within such an approach, psychotherapy is understood as a technical means to bring about a predetermined end. Scientic investigation of psychological problems provides the basis for psychotherapy as a technology of change. This view of psychotherapy as applied science truncates questions about the good that therapy may do. The assumption is easily made that improvement in symptoms, functioning, or reports of distress, is all the good we need be concerned about. Ethics in this context becomes the professional obligation to provide the best means to bring about these ends. This approach to understanding psychotherapy and therapeutic benet is clearly evident in the Empirically Supported Treatments (EST) program (Chambless & Hollon, 1998; Chambless & Ollendick, 2001; Task Force on Promotion and Dissemination of Psychological Procedures, 1995), an effort to establish a list of treatments of proven efcacy. Through a cri-
tique of this program, I will challenge the validity of the technological model of therapy upon which it relies. At the heart of the critique lies a series of interconnected ideas about psychotherapy: 1) The problems people bring to therapy cannot (or can only rarely) be understood technically, as separable components of the person that are not interconnected with who the person is. 2) These problems will be implicated in some important ways in how the person understands herself, her world, and what constitutes a good life. 3) To do psychotherapy necessarily involves engaging the person in a way that touches upon these broader concerns. 4) Since psychotherapy is a moral engagement with the client in the context of these broader concerns, ethics is fundamental to what therapy is, not simply to how it is done (the term moral engagement comes from Miller, 2004). 5) As a moral engagement, therapy does not t the technological model of the EST program.
Kevin R. Smith, private practice, Pittsburgh, Pennsylvania. I thank Constance Fischer, Jane Matz, and Paul Pilkonis for helpful comments on earlier drafts of this paper. Correspondence concerning this article should be addressed to Kevin R. Smith, 552 North Neville St., Suite A, Pittsburgh, PA 15213. E-mail: kevinregansmith@hotmail.com
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tices be supported with evidence of their efcacy. The EST program can be seen as a natural development of some prior psychotherapy research that attempted to assess the relative efcacy of different therapies. Whether a psychotherapy is effective or not can only be determined empirically, by gathering data regarding outcome in comparison to other treatment and/or placebo (see the summary of various proposals for specic EST criteria in Chambless & Ollendick, 2001). Research on efcacy can only proceed through specication: it is necessary to specify the treatment and what is being treated. Psychoanalysis is not Gestalt therapy; relaxation training is not exposure-based behavioral treatment. Likewise, obsessive compulsive disorder (OCD) is not schizophrenia, enuresis is not alcoholism, and loneliness is not unhappiness in ones profession. In order to determine which therapy works for which problems, the best approach is to examine the efcacy of a welldened treatment for a well-specied problem or disorder. The operative framework here is technological. This framework proposes that psychological suffering can be analyzed into welldelineated and speciable problems and their causes which, when carefully investigated, will yield specic methods of intervention. The descriptive differences among problems and disorders must be explainable in terms of relevant etiologic or maintaining factors that dictate different approaches to treating them. This framework comes through clearly in the comments of many who support the EST approach to evaluating treatment. For example, Chambless and Crits-Christoph (2006) claim that identication of the effective elements of successful treatment cannot be done on the basis of clinical experience alone:
Can clinicians reliably assess and remember accurately what the causal factors were in their clients improvement? Without systematic research, it is unlikely that amid all the variability and uncontrolled factors in treatment outcome, clinicians can be condent about which of their many behaviors are consistently related to the results of treatment for a particular type of client or problem (p. 194).
job is to apply a treatment which effectively targets those factors. Supporters of the EST program have noted the ethical implications of this conception of the therapists task. For example, Chambless and Crits-Christoph (2006) argue that:
In the face of evidence that Treatment A works, it is not sufcient for the practitioner who prefers Treatment B to rest on the fact that no one has shown that Treatment B is ineffective. Treatment A remains the ethical choice until the success of Treatment B has been documented, unless in the process of informed consent the practitioner describes the alternatives and evidence for each, permitting the client to make an educated decision (p. 193).
One implication of the EST program is that one of the therapists fundamental ethical obligations is to provide a treatment of proven efcacy from a list of ESTs.
According to the technological model of therapy, what the therapist does depends upon a prior assessment of the nature of the clinical problem through scientic analysis of underlying factors that cause the problem. The therapists
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dick & King, 2006; Shapiro & Shapiro, 1982), or dismantling studies which show that some techniques are more effective for a given problem (Woody & Ollendick, 2006). Research has repeatedly shown that relaxation training is not as effective for OCD as exposure plus response prevention (Chambless & Ollendick, 2001). Ordinary clinical experience is often in agreement. Who today would recommend psychoanalysis for someone who is spending several hours a day in elaborate ritualized washing and showering to avoid contamination? It is not just fashion or propaganda that has led clinicians to abandon certain treatments as inappropriate for some problems. Proponents of the EST program argue that it simply adds more rigor to what clinicians routinely do in making treatment decisions. Some who are generally convinced regarding research support for UTE are willing to make some concessions to those who advocate for the EST program. Treatment for OCD is the kind of case where such concessions are made. Westen, Novotny, and Thompson-Brenner (2004) make a distinction between circumscribed disorders like OCD, specic phobia, or panic symptoms, and noncircumscribed disorders like depression. Noncircumscribed disorders are woven into broader aspects of the persons life (personality, relationship history, coping style, sense of self). One consequence is that there will be multiple points of entry into the problem that can make a difference. Hence many types of therapy and therapeutic techniques will be successful. Circumscribed disorders involve a link between a specic stimulus or representation and a specic cognitive, affective, or behavioral response that is not densely interconnected with (or can be readily disrupted despite) other symptoms or personality characteristics (p. 655). Not all would make this concession. Wampold (2007) maintains a more sweeping skepticism about the prospects for showing the superior efcacy of specic treatments. I am inclined to leave the door open for the possibility of a technologically conceived treatment of superior efcacy for a circumscribed disorder. It would be difcult to prove that there are no psychological problems which lend themselves to a technical intervention. However, whether a given clients problems are circumscribed in this sense will not be decided by diagnosis alone. It is not difcult to nd cases of appar-
ently circumscribed disorders which turn out not to be (for examples, see Wolfe, 2005, pp. 3 4, on a specic phobia, and Gabbard, 2005, pp. 266 267 on an OCD case).
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If psychological problems were of the circumscribed sort that could be resolved by technical means, then morale would be at most a helpful adjunct to the technical work of xing the problem (like the optimism of a patient headed into surgery). To conceptualize remoralization this way would be to misconstrue the model proposed by the Franks as being merely an adjunct to the technological model. Theirs is in fact an alternative model which shows remoralization to be more than the enhancement of attitude or morale. It occurs through a revisioning of the problem, a shift in how it is understood and lived with that changes the problem itself. A new, more coherent picture of the clients life course reduces anxiety and enhances the clients sense of well-being by helping the client to make better sense of what he is experiencing.
prevent her from returning to her sport. She may be about to embark on a walking tour of Ireland with her husband of 20 years in a last ditch effort to reconnect in a marriage that has been in trouble for some time. But the problem itself does not reveal these personal meanings: no amount of investigation of the injury to her foot, no examination, X-ray, MRI, will reveal any of these possible personal signicances. One may object by varying the example. What if the patient about to travel to Ireland were to say, Oh, I hate myself for being such a klutz that I am always injuring myself. It is true that a personal signicance appears here. But the signicance concerns some skill or grace she lacks, a skill or capacity to live well that belongs to the kind of person she would like to be. The injury itself is only a sign or consequence of that lack. With psychological problems the client will often experience the problem itself as living poorly, not as the consequence of a failure to live well. Clients understandings (often only implicit) of what is most important to them, what they aspire to, what living well is, are partly constitutive of their psychological problems. I do not want to claim that this is necessarily the case in every instance. Nor do I mean to suggest that only psychological problems implicate notions of a good life. Many actions, choices, thoughts and feelings do that, not just those that are typical of psychological disorders. My point here is to show that fairly ordinary psychological problems are commonly interwoven into more fundamental concerns about a good life. Consider someone suffering from panic attacks. Often the problem is presented as something to be gotten rid of, as though it were a circumscribed problem. But consider how this complaint about panic attacks can shift when the person speaks of how embarrassed or ashamed she is of her panic. I dont have that much stress in my life. Other people manage life without panic. I feel like Im a loser, like I cant control myself. I guess I know that panic attacks wont really hurt me, so why do I freak out about them? I wish I was stronger. Other people would think I was crazy if they knew about it. Its like when I dropped out of college several years agoI felt like everyone was looking at me like I was a loser. It doesnt help that everyone else in my family is so successful.
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They treat me like the one whos never going to make it. Sometimes I wonder if I want to make it. Now I think maybe I just cant. The client believes that being afraid like this is irrational, and sees it as a failure to be the kind of person she wants to be. The therapeutic conversation that ensues will be at least in part about what the person thinks is important for herself, how she assesses her life, and whether it is on track toward some good that matters to her. The excessively harsh self-criticism of a depressed patient (one who suffers from what has been called introjective depression, Blatt, 2004), may be part of a demand to achieve some good. This person may feel that to live his life well he must succeed at achieving this goodno excuses, no shirking. To help this person change how he lives with and understands his obligations and expectations to succeed at what is important to him is to help bring about a change in his depression. But the change occurs not because one has removed the cause (harsh demands to meet obligations) of the depression. These demands are part of what the depression is. It makes less sense in this context to think of depression as something the person has (a disorder) than as a way the person is living and experiencing himself and his world. To conceptualize the depression as something apart from him with which he is inicted is already to begin to take a technological stance toward the situation, where one is drawn to target the disorder. But if it is a way of thinking, experiencing, and living, then to respond therapeutically to the person who is depressed is to join with him in his world and look for ways to move somewhere else, or other ways to inhabit his world, other ways of living, experiencing. In doing so the person changes, not by shedding a disorder like an infection, but by taking on a different perspective, a different sense of who he is, what his world is like, or what matters most. There are problems with a cause-effect model for explaining psychological problems (harsh self-criticism constitutes, not causes depression). Further, efforts to address such problems are not technical means to bring about a separate end. Therapy engages the person in a process of reorientation, of change in her sense of who she is, of what matters to her, that constitutes a change in who she is. The fact that a cause-effect, means-end model does not t well
what happens in therapy is at the heart of what makes the technological model of therapy problematic. It can be a difcult model to relinquish for those who see themselves as scientistpractitioners. Miller (2004) has discussed how this model of psychologists professional identity has created problems for developing a clearer understanding of therapy. With the expectation that therapy be an applied science often comes the idea that the only alternative is blind prejudice, ideology, or wishful thinking. One way to begin to address such concerns is to show that there are other models of knowledge, and of good practice based on that knowledge, than the technological model of applied science. Miller (2004) and Woolfolk (1998) have noted the value of Aristotles distinction between poiesis and praxis in this regard. Chapter 6 of the Nichomachean Ethics (Aristotle, trans. 1976) makes a distinction between human activity, poiesis (production or making), that is intended to bring about something other than itself, and an activity, praxis (action), which does not aim at an end separate from itself, but only aims to do well. For production aims at an end other than itself; but this is impossible in the case of action, because the end is merely doing well (Aristotle, trans. 1976, p. 209). Typical examples of production for Aristotle are shoe making and house construction. Shoe making aims at an end other than itself, the shoe, which in turn is a means to something else (walking, protection of the foot). Whether one has done well in production is determined by an assessment of the end product (it is a good shoe insofar as it serves well the purposes for which it was made). With praxis it is the action itself that is evaluated, not some separate product that it creates. An example of praxis is courageous action. To stand and ght despite the danger of battle, to rush into the burning building to save the child, is courageous regardless of the outcome, even if the battle ends in defeat, or the child is not saved. Likewise, to fail to be courageous, to be cowardly or foolhardy, is also not determined by outcome. One is no less cowardly for not acting to save the child because the child managed to nd a way to save herself. Aristotles discussion of poiesis and praxis occurs in the context of a discussion of the kinds of knowledge associated with them. To production or poiesis corresponds techne, technical
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skill, a productive state that is truly reasoned (Aristotle, trans. 1976, p. 208). Those who have this technical skill know both what end they are seeking, and how to bring this end about. Dunne (1993) characterizes Aristotles techne as the source of the makers mastery of his trade, and of his ability therefore not only to accomplish a successful result (which any handy person might be equally capable of) but in doing so to give a rational account of doing so (p. 250). Psychotherapy as applied science would exhibit techne. The person who is engaged in production who has techne has knowledge of an end and works his material to bring about that end. By contrast, praxis requires not techne but phronesis (often translated as prudence). Someone engaged in praxis who exhibits phronesis has his interest not in an external product but in who he is or becomes through his actions. The function of phronesis is not to maximize a good that one already knows and can come to have, but rathera much more difcult taskto discover a good that one must become (Dunne, 1993, p. 270 italics in original). Therapy as practical moral engagement is a conversation that recognizes the clients involvement in this more difcult task. The inherently ethical nature of therapy becomes clearer when one conceptualizes therapy not as production, not as a technical process that treats or removes a disorder that the person has, but as an aid to the clients praxis, to a process of discovery of a good he seeks to become. The changes that occur in therapy are in some sense a change in who the person has been. Part of what constitutes a persons sense of who they are is where they stand in relation to some good, some notion (however vague or unarticulated) of what is a better or worse life, what makes their own life seem good or bad, worthwhile or worthless, and so forth. Who one is, is partly determined by such notions. This is an oft repeated theme of Charles Taylors (1985, 1989) work on human agency and personhood. The human agent not only has some understanding (which may be also more or less misunderstanding) of himself, but is partly constituted by this understanding (Taylor, 1985, pp. 3). Further, this self-understanding includes a moral component. Persons only exist in a certain space of questions, through certain constitutive concerns. The questions or concerns touch on the nature of the good that I orient myself
by and on the way I am placed in relation to it (Taylor, 1989, p. 50). Taylor is critical of the idea that one can develop a human science that ignores the constitutive role of this orientation to the good. His target is a picture of human agency as weakly evaluative, as simply calculating how to attain that which is desired. By contrast he speaks of people as also essentially involved in strong evaluation, where they are concerned not just with what they desire, but with a qualitative characterization of desires as higher and lower, noble and base, and so on (Taylor, 1985, p. 23). In a passage that echoes Dunne (1993) on phronesis, Taylor writes that strong evaluation is not just a condition of articulacy about preferences, but also about the quality of life, the kind of beings we are or want to be (1985). To refer to a way of living, of understanding oneself, in terms of ones orientation to some notion of the good may suggest a fully articulated concept of the good, even the selfconscious endorsement of a particular philosophical school or religious belief. But the fact that the problems people bring to therapy often implicate some understanding of what constitutes a good life does not mean that therapy is a straightforward discussion of philosophical or moral positions. As the depressed person talks of situations where he is relentlessly judgmental of his failure to meet his standards, subtle shifts may occur that are not expressed in an explicit statement about self-judgment. There may be no declaration that, I see now I shouldnt be so harsh with myself. Much of what people believe about what is good and bad for themselves is not explicitly articulated, but lived. Therapeutic change likewise often takes place at the level of the lived, rather than the fully articulated. But this does not make the changes in such lived beliefs any the less an alteration of some view of what the good life or human ourishing consists in. Doing therapy is an engagement with people that speaks to and creates changes in these moral notions. To refer to someones sense of the good as a moral concern broadens the term moral to include much that would not be considered moral in contemporary culture. Someones sense of what would constitute a good life may include holding to standard moral prescriptions (to be honest, or kind to others), but may also include other goods (to be perceptive, cool,
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original, strong, prosperous, etc.) that are moral only in the Aristotelian sense of being part of some conception of a good life. (As the last examples suggest, the content of a contemporary list of goods will include items Aristotle would not recognize.)
an ancillary enterprise, at worst as potentially undermining these other fundamental goods. Consider the response to the EST movement from Division 32 of the American Psychological Association (APA), Division of Humanistic Psychology (Task Force for the Development of Practice Recommendations for the Provision of Humanistic Psychosocial Services, 2004). In this document, psychotherapy is valued not primarily for its capacity to diminish symptoms or improve functioning, but because it can promote psychological development. The latter is described as including:
Greater capacities for self-understanding, understanding of others, and understanding of relationships; clarication and development of values and life goals; development of a greater capacity for deep experiencing; the strengthening of relational bonds; the promotion of an environment of mutual care and empathy; development of a greater sense of personal freedom and choice while respecting rights and needs of others, as well as the limits imposed by reality; and the strengthening of individual, relational and group agency (p. 5).
There is an explicit rejection of the idea that the most important way to assess therapy is in terms of its ability to change some specic symptom or behavior.
Humanistic psychotherapists. . .do not see effectiveness in terms of a methods ability to operate on clients and change them, but rather in terms of the kinds of conditions therapists provide which allow clients to take their pain seriously, explore their lives, and nd more meaningful ways of engaging in their existence (p. 11).
If there is an effort to alleviate specic symptoms, it is done as part of the larger context of exploring broad personal issues and problems of meaning (p. 19). Humanistic psychotherapists are not alone in refusing to focus exclusively on therapys power to remove symptoms or change behaviors. McWilliams (2005), a psychoanalyst, questions an exclusive focus on symptoms and functioning. She proposes that one of the benets of psychotherapy could be to challenge the dominant individualistic, consumerist, and technocratic values of our culture with therapeutic values derived from the psychoanalytic, humanistic, and existential traditions: self-understanding, authenticity, empathy and compassion, egalitarianism, adaptation to unchangeable realities, growth in agency and personal responsi-
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bility, acceptance of normal dependency, and respect for others as subject rather than object. A therapy conceived in these terms is one which sees the client as a moral agent whose suffering is responded to with an effort to develop or strengthen certain virtues (selfunderstanding, empathy, authenticity, etc.). The effort to develop such virtues is not undertaken simply as a means to treat the symptoms of a disorder. For example, David Shapiro (1989) writes of his psychotherapy for neurotic character as attempting to address self-estrangement, an aim that distinguishes his therapy from classical analysis.
It is not an estrangement of a rational adult consciousness from an intrusive, now irrational childhood wish. It is a self-estrangement of a more general kind. It is a distortion or loss of self-awareness, an estrangement of reective or articulated consciousness from the actuality of a largely unarticulated and diffuse subjective world. To put it more simply, it is an estrangement between what one thinks he feels or believes and what he actually feels or believes (p. 28).
Shapiro describes this self-estrangement in the context of various examples of the suffering and symptoms it helps to create: recurrent interpersonal problems, depression, obsessive rumination, and so forth. The implication is clear that psychotherapy that addresses this selfestrangement will help alleviate suffering and symptoms. But if someone suggested she could alleviate distress and symptoms without changing the clients self-estrangement, would this be acceptable? Is overcoming an estrangement between what one thinks one feels or believes and what one actually feels or believes simply a means to an end? Or is there not some sense that Shapiros psychotherapy is providing some good to patients in overcoming self-estrangement that goes beyond its value in overcoming depression, obsessive rumination, and so forth? In light of the discussion of praxis above, it would be more accurate to view overcoming self-estrangement not as a means to less psychopathology, but as constitutive of that change. The exploratory/expressive therapies promote an openness to nuances of meaning and subtleties of the moment. They often attend to that which is not easily pinned down or univocally identiable, that which shifts and is transformed as it is attended to and articulated. An openness to whatever appears is valued partly
because it allows something specic to appear. For example, I have responded to a clients fear of feeling exposed by being careful not to push him to talk about a sensitive topic. But my carefulness doesnt seem to be reassuring to him or feel supportive. In fact, he seems more guarded, speaking less expansively, and starts focusing on some irrelevant detail. It seems that my cautiousness hasnt come across as giving him time to come to this when he is ready, but appears to signal that I too am afraid to enter into this sensitive subject. Perhaps hes surprised I am not pushing him and this leads him to wonder where I am, what I am not saying. But when I nd some way to talk with him about my caution and its effect on him, we both recognize something we have been doing, and relax. My openness to how I am affecting this client differently than I intended leads me to see him closing down. And I address it in order to help both of us stay open. Particulars come out of this (about his shame, my hesitance to intrude). But the openness that allows the particulars to appear begins to take on a value of its own as that which helps one not to be too entangled in any particulars. This openness is not brought about by some technical intervention. It is enacted in the doing of a therapy which invites the client to join me in enacting it himself. As Miller (2004) puts it, Whatever the therapeutic goal, therapy consists of exposing the client to small, regular doses of that end (p. 91). Just as psychological problems implicate the clients search for a good he seeks to become, so psychotherapy is a praxis that enacts some good. Something similar can occur in more technologically oriented therapies. What begins as a means to an end (effective techniques for the change of behavior or removal of symptoms) begins to take on a value of its own. A fundamental picture of the person is operating here as surely as in the therapies that espouse openness or authenticity. A technologically oriented therapy can claim neutrality with regard to larger issues regarding the nature of persons, human agency, or the good, only to the extent that it is directed at circumscribed disorders which do not implicate the person as a whole. Outside of this delimited range of problems, the application of this technological approach becomes the espousal of a particular philosophy of the good. It is as though the technological therapist says to
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the person seeking therapy: The best way to live is to treat yourself as a free agent whose aims can and have been freely chosen, but the pursuit of these aims is impeded by emotional or behavioral hindrances. Your interests are best served by setting about the task of removing the obstacles that interfere with the pursuit of your aims. Psychotherapy can help you to do this. This view of a good life is not the obvious default position to which we all must subscribe. It is largely rooted in and consonant with some version of liberal individualism (see Bellah, Madsen, Sullivan, Swidler, & Tipton, 1985; Richardson, Fowers, & Guignon, 1999; Woolfolk & Richardson, 1984). If a client raises questions about which aims are really worth pursuing, whether these aims are really her own, or considers the possibility that her distress or symptoms might be an indication that there is something amiss with the aims she nds herself pursuing, then the application of a technological approach becomes something other than a means to remove obstacles to effective functioning. It becomes an implicit proposal to understand oneself (not just ones circumscribed disorder) technologically. Further, since liberal individualism claims to be neutral with regard to views of the good life, to only be a method to aid someone who already knows what she wants, it can wind up with nothing to say to a client who raises such questions. Worse, it may implicitly provide a model for how one answers them (it is a matter of personal preference) that can suggest that there are no standards for choosing, thereby diminishing the seriousness of such questions (Richardson et al, 1999, and Taylor, 1989, discuss this point in more detail). Perhaps a case can be made that even with noncircumscribed disorders it is sometimes better to take a technological orientation toward oneself, that to do so makes more sense and will bring one closer to a good life than the search for authenticity or self-understanding. But that case will not be made simply by showing superior efcacy in achieving symptomatic improvement. To focus the search for good therapy on efcacy is to surreptitiously propose a picture of who we are and of what the good life is for us in such a way that questions about why this picture rather than another never get raised. The EST movement
presents itself as a scientic program to address delimited problems, when it is also proposing a view of human ourishing that is not getting the open hearing, and debate, that it deserves.
Evidence-Based Practice
Another complication concerns the superceding of the EST program by the broader program of evidence-based practice in psychology, EBPP (see APA Presidential Task Force on Evidence-Based Practice, 2006). The views put forward in the Task Force report on EBPP are
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more comprehensive and less single-mindedly focused on therapy as technology than one nds in the EST program. The report emphasizes that research should focus not just on the efcacy, but also on the applicability, usefulness, and generalizability of an intervention. This data from an expanded research focus is in turn to be integrated with clinical expertise in the context of patient characteristics, culture and preferences (APA Presidential Task Force on Evidence-Based Practice, p. 273). The reference to patient culture and preferences points to the limits of a technological view of therapy, for cultures always include some picture of a good life. However, the EBPP report does not acknowledge the ways in which the psychotherapies also include cultures, their own views of a good life. Further, much of the discussion of patient characteristics, including culture, takes them up as factors which inuence choice of treatment and outcome. The implication is that improved data on these factors will enhance the efcacy of treatment. Better basic science will lead to a better applied science of psychotherapy. So while the EBPP report adds nuance to the picture of therapy, it continues to include some emphasis (if not so exclusive an emphasis) on a technological model of therapy that does not address many of the issues I have raised above.
choanalysis was dominant in American psychiatry, both analysts and analysands saw themselves as participants in a therapeutics that was based upon the application of a complex set of technical procedures to this end [the cure of neurosis] (p. 201). And on the other side, Albert Ellis (1962), the grandfather of cognitive behavioral therapy, is well known for taking strong stands on moral, philosophical, and religious views, and for understanding his therapy as rooted in these stands. My critique concerns the limits of a technological model of what therapy is, regardless of which school this model is applied to.
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views, which over time can come to make it appear unrecognizable as another instance of the same school. This is true of the formal theory of the school, of its practices, and of the views of human ourishing which are embodied within it. Overviews of the school with the longest history, psychoanalysis, make this clear (Greenberg & Mitchell, 1983; Sandler & Dreher, 1996). If one considers the multitude of conceptions of a good life in the many schools and orientations to doing therapy beyond psychoanalysis, the variety is astounding (even if there is also overlap). Questions arise here as to the origins of all these views of a good life. There have been many attempts to address this (Bellah et al., 1985; Cushman, 1992, 1995; Richardson et al., 1999; Reiff, 1966; Taylor, 1989, 2007). But even more important (though not unrelated to the question of origins or genealogy) is how one adjudicates between such competing views. One inclination for the psychotherapist who understands herself to be an applied scientist may be to try to nd some scientic basis that assesses such views from the outside so to speak. McDowell (1995, 1998) argues against the attempt to nd a scientic, extraethical standpoint from which to carry out such a task. Taylors (1989) work on practical reason in chapter three of Sources of the Self, is one attempt to show how the weighing of competing views of a good life can (and must) happen from within the picture of the good one already has. Again, what can be said in the context of this paper is that one cannot avoid this important issue by claiming to only be doing a technical therapy that avoids ideas about a good life.
that phronetic deliberation is not a process of applying general rules to specic cases, nor is it an instance of scientic methodology. Similar critiques of the rules/cases model are made by McDowell (in his paper, Virtue and reason, in McDowell, 1998) and Wiggins (1980). Perhaps more germane to the topic of this paper is the philosophical return to Aristotles ethics as the basis for a critique of the modern assimilation of human science to natural science. The techne/phronesis distinction has often been an important part of this critique (see, e.g., Gadamers discussion of the hermeneutic relevance of Aristotle in Truth and Method, 1965/ 1975, pp. 278f). The history of this critique is long and complex. Volpi (1999) gives an overview of German neo-Aristotelianism that places Gadamer in the context of other work which reexamines the human sciences in light of practical philosophy. There are striking differences among the major gures in this eld. Bernstein (1991) sees a fateful signicance in the fact that Heidegger focused on the contrast between techne and episteme in his analysis of technology, while Gadamer focused on the techne/ phronesis distinction. There are further ripples out from these philosophers that return directly to psychotherapy. Both Sterns (1997) psychoanalytic therapy and Cushmans (1995) moral-critical therapy borrow directly from Gadamer in ways that repudiate a technological model of therapy. Bohart and Tallman (1999), who are not directly inuenced by hermeneutic philosophy, put forward a model of therapy as collaborative conversation which has afnities with Stern and Cushman. Clearly, the techne/phronesis distinction has ramications far beyond the uses to which I have put it in this paper. I have used it here for two purposes: 1) to think beyond the technological model of therapy in a language which dovetails with Taylors hermeneutic critique of a technological model of human science; and 2) to highlight the central role of views of a good life in both psychological problems and the therapy intended to address them.
References
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