Digesting psychotherapy

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12 November 2012


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Book coverTherapy Beyond Modernity: Deconstructing and Transcending Profession-Centred Therapy
Richard House
Rating 2.5
Karnac, London, 2003; ISBN 1855759969
Review published in Ipnosis No 9, Spring 2003
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This is a stimulating and thought-provoking book, written with obvious passion for the subject and sincere concern about where psychotherapy and counselling are going. Richard House's central argument is "that, in its profession-centred, commodified form, therapy can and sometimes does become routinely and intrinsically abusive to the extent that it self-fulfillingly constructs a framework ... which serves to guarantee the legitimacy of its own existence within a discursive regime of truth, and outside the confines of which it can become very difficult for clients and therapists even to think." (italics added) Strong talk indeed, followed by a debate which usually rises to the occasion! By drawing on an interesting diversity of sources, the author carefully examines and deconstructs many of the shibboleths of professional therapy before suggesting various ways in which therapy might better serve clients and help establish its integrity in the future. Comprehensive references and an extensive bibliography are also helpfully provided.

Psychoanalytic and psychodynamic concepts are particularly vulnerable to a deconstructive spotlight, as the critiques of therapy by former clients Rosie Alexander, Ann France and Anna Sands confirm. House devotes a chapter to each of these works, aiming to illustrate how profession-centred therapy's "regime of truth" severely affected their therapeutic experiences. The observations made in these individual cases are certainly pertinent but, as the author reminds us, they should not be generalized to the full spectrum of therapeutic practice in the country. His primary concern is private, one-to-one therapy. However, without a wider examination of therapeutic practice, for example, within the National Health Service and voluntary sector, the picture for society as a whole is incomplete.

Looking towards the future, the author describes a 21-point framework for a "post-professional" - more client-serving and less self-serving - therapy. He identifies some pioneers of such an approach, notably Freud's contemporary Georg Groddeck (to whom a whole chapter is devoted), and the spiritual teachers Jiddu Krishnamurti and Rudolf Steiner. The discussion of their philosophies at work highlights valuable alternatives to "the modern technocratic mentality". Perhaps surprisingly, general practice counselling is suggested as a fertile ground for "postmodern" therapy. More expectedly, the Independent Practitioners Network is used to illustrate an appropriate form of practitioner community. It may also have been helpful to mention the growth of initiatives, such as the Heroic Client Network and the CORE system, which can make the therapeutic process much more responsive to clients' perceptions of progress.

Richard House mostly reasons and argues his case well, and there is generally a refreshing honesty and openness to learn evident throughout the book. "I do not by any means present my arguments as the truth about therapy - as somehow being a 'better' regime of truth than that which it is replacing." Though, having acknowledged some significant findings from research, notably the dominance of non-specific healing factors to outcome, the author says: "I believe that any 'objective' empirical research is in principle impossible in this highly peculiar field - in which case subjective, impressionistic data is at least as reliable as any other." (italics added). Surely this kind of unscientific bias in the past is one of the main reasons why professional therapy is now in the very state which the author laments! The growing corpus of good research data now available (reviewed by, for example, Wampold (2001), Hubble, Duncan & Miller (1999) and Bergin & Garfield (1994)) has exposed several significant flaws in current professional practice and would, ironically, substantiate several elements of House's "post-professional" framework. However, David Smail's Afterword does briefly discuss the positive contribution which science can make to therapy.

While recommended to thoughtful practitioners, I suspect that the book may have only limited appeal to, and impact on, the public, funders and politicians. The philosophical language and academic style used will tend to restrict its readership. For example, what would many clients make of "a processually deconstructive therapy" [tending to] "privilege notions of the indissolubly co-creative intersubjectivity of human relationship in its therapeutic ontology rather than an intra-psychic, subject/object, observer/observed ontology"? Also illustrating the point, the reviews on the back cover all come from academia - four Professors and one Reader!

Despite some criticisms above, I am glad that Richard House has written courageously to shake off complacency and dared us to challenge therapy's "business as usual". He has examined many important issues which deserve much wider and more open debate than exists at present. This book makes an important contribution to the dialogue. We need more works like this if professional psychotherapy is to live up to its own rhetoric as a truly ethical and reflective endeavour.

Book coverImplausible Professions: Arguments for Pluralism and Autonomy in Psychotherapy and Counselling
Richard House & Nick Totton (Editors)
Rating 3
PCCS Books, Ross-on-Wye, 1997; ISBN 1898059179
Review published in The Therapist Vol 5 No 1, Winter 1998
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This anthology effectively challenges many of the myths and assumptions on which the 'professionalisation' and commodification of psychotherapy and counselling in the United Kingdom are based. The editors introduce the book by describing the current state of professional play in these fields and state that "the project of this book originated as one of opposition; but it has developed first into one of refoundation, and then into one of innovation."

Thirty essays from twenty-four authors creatively argue the case for pluralism and autonomy, and although around a third of the essays have been published before, some have been updated and all make valuable contributions to the anthology. Indeed, some (like David Wasdell's In the Shadow of Accreditation) have become classic references in the debates about professionalisation and this book conveniently brings many of them together for the first time.

Richard Mowbray's two chapters bring his seminal work The Case Against Psychotherapy Registration right up to date, concluding that: "Two years on, despite some 'huffing and puffing' and resort to personal invective, the arguments and evidence I assembled have not been refuted nor even credibly challenged." It is also notable that two Fellows of the British Association for Counselling, Colin Feltham and Brian Thorne, have contributed mature reflections which seriously question key elements of that association's aggressive drive towards practitioner accreditation and registration.

In addition to thorough explorations of the usual "professional" issues of training, ethics, accreditation and regulation, there are insights into impinging fields as diverse as spirituality, politics, tragedy, research and audit. The editors' brief tale of how the book almost failed to be published because of nobbling by vested professional interests and Richard House's summary of the work of the pioneer Georg Groddeck are juicy little extras to savour.

The nascent Independent Practitioners Network is given particular prominence in later chapters as an alternative non-hierarchical model of accountability for practitioners.

With such a wide range of contributions, the book will undoubtedly arouse passions both for and against the viewpoints taken in particular essays. As House and Totton remark in their introduction: "We are two strong-willed individuals with often very different views about both style and content. The fact that we have successfully produced this book is in itself a strong argument for pluralism as a creative process!" The one significant criticism which I would raise, although not wishing to detract from the book's intrinsic value, is that the debate could have been informed further by the outcome research which has identified common factors underlying all effective psychotherapy.

Overall, the editors have achieved their aims admirably with this stimulating book which will have appeal to any psychotherapist or counsellor concerned more with therapeutic effectiveness than professional status. House and Totton conclude: "It seems clear that psychotherapy and counselling will remain incorrigibly diverse and indefinable, no matter how much 'therapy' the field receives - either from its discontented radicals, or from the proponents of establishment and professionalisation." The last word on the "implausible professions" should perhaps go to Mowbray: "As and when clients and the public at large wake up to the fact that the rush to register is not in fact for their benefit, the credibility of individual registrants is also on the line through their participation in, and funding of, the process."

Book coverThe Heart and Soul of Change: What Works in Therapy
Mark A Hubble, Barry L Duncan, & Scott D Miller (Editors)
Rating 4
American Psychological Association, Washington DC, 1999; ISBN 155798557X
Review published in The Therapist Vol 6, No 3, Summer 1999
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This substantial volume (462 pages) has two ambitious but worthy aims: to summarize the evidence for "what really works" in psychotherapy; and to propose how this knowledge can make therapeutic practice more effective. With contributions from 24 leading practitioners and researchers, the editors present a compelling case for the importance of pantheoretical or common factors in successful therapy.

The Heart and Soul of Change systematically dismantles the belief that therapy models and techniques matter most and lays an empirically validated foundation of how people actually change. It describes how four decades of psychotherapy outcome research has failed to identify one (or more) consistently superior therapy. "Besides the occasional significant finding for a particular therapy, the critical mass of data revealed no differences in effectiveness among the various treatments for psychological distress."

The general finding of equivalent outcomes has three possible explanations. First, different therapies achieve similar goals through different processes. Second, different outcomes do occur but have not been detected by past research. Third, different therapies embody common curative factors.

The third possibility has received the most research attention and has the clearest implications for practice. The Heart and Soul of Change carefully investigates Michael Lambert's proposed 'big four' grouping of common factors: client/extratherapeutic factors; therapeutic relationship factors; placebo, hope and expectancy factors; and model/technique factors. It is estimated that, on average, these factors contribute to a successful outcome in the ratios of 40:30:15:15 percent respectively. Specific factors attributable to different therapies and techniques do matter, but "their principal contribution to therapy comes about by enhancing the potency of the other common factors."

The book is divided into four well-balanced parts. The first part gives an overview of the empirical support for the common factors and the second reviews each of the 'big four' factors in detail. An additional chapter on how people change and how change may be integrated with the common factors has been provided by James Prochaska. He suggests ways in which, by assessing the stage of change, mental health care can be targeted more effectively, both in individual cases and in the wider population. The role of the common factors in medicine, drug therapy, marriage and family therapy, and school and educational settings is explored in part three.

Part four examines the implications of the common factors for health care reimbursement, clinical practice, the client's role in therapy and the future of therapy. At the end of each chapter, the contributors answer three questions posed by the editors on the main issues raised. The responses provide further insight and useful practical guidelines. In particular, the implications of the common factors for the training of therapists are sobering: the current teaching and supervisory edifices built around theoretical orientations are not justified. "Client outcome is principally determined by client variables and extratherapeutic factors rather than by the therapist or therapy."

The editors themselves contribute the book's opening and closing chapters. They discuss the economic and professional pressures which have maintained the longstanding schism between psychotherapy research and practice. With the efficacy of psychotherapy now generally accepted, there has been intense competition between and within the mental health professions. Therapy models and associated techniques have proliferated (rising to approximately 200 and 400 respectively), and claims and counterclaims of their efficacy have been vigorously defended. Hubble, Duncan and Miller argue convincingly that the field has become so preoccupied with finding a winner among therapies that it has lost sight of what outcome research has persistently been telling us about therapeutic effectiveness. They warn us that, if current fashions continue, control of psychotherapy's destiny will slip even further into the hands of other professions, insurance companies and politicians. The challenge to psychotherapy is illustrated by the rush to establish empirically validated treatments (EVTs) and the increasing regulation of treatment dosage, mode and setting by managed care companies.

The earlier title Escape from Babel launched the editors' collaboration on therapy commonalties, and it remains a valuable overview in its own right. The Heart and Soul of Change successfully extends this work by providing many additional perspectives on the research findings and practical implications. With the much-respected Handbook of Psychotherapy and Behaviour Change now is in its fourth and final edition (edited by Bergin & Garfield), The Heart and Soul of Change was conceived as a new handbook on the common factors. It fulfils this role admirably and should be of great benefit to academicians, trainers, trainees and practitioners. The editors and writers have skilfully managed to transcend the civil wars in psychotherapy and bring a real sense of maturity and peace to the field. However, no doubt unintentionally, they have also thrown down a challenge to psychotherapy in Europe. All the contributors to The Heart and Soul of Change are based in North America and obviously sensitive to the particular commercial and cultural strictures which affect psychotherapy within that continent. Can Europeans learn from the American experience, and, by focusing on what really matters in psychotherapy, start to close the credibility gaps in training and practice which currently exist throughout Europe? If the mass of research evidence continues to be ignored, the future existence of psychotherapy as a distinct, non-medical helping profession may well be at stake. As Hubble, Duncan and Miller say: "The ship is sinking and all the gurus seem able to do is argue over which way to arrange the deck chairs." The Heart and Soul of Change offers a welcoming lifeboat to effective psychotherapists and their clients.

Book coverEscape from Babel: Toward a Unifying Language for Psychotherapy Practice
Scott D Miller, Barry L Duncan & Mark A Hubble
Rating 4
W W Norton, New York, 1997; ISBN 0393702197
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With a clever title, this superb book represents the authors' first collaborative writing venture. They skilfully argue from four decades of research evidence that most of the benefits of psychotherapy arise from the commonalities found across the spectrum of therapeutic approaches. Many longstanding myths about therapy are exploded on the way.

Extratherapeutic factors (contributing on average 70% to outcome), therapeutic relationship factors (30%), placebo, hope and expectancy factors (15%), and model and technique factors (15%) are all considered in detail and clear suggestions are given as to how they can be harnessed in practice to improve client outcome. The importance of matching the processes of therapy to the client's stage of change is also discussed. The authors' recommendations for practice are highly practical and are illustrated by very informative case studies.

Escape from Babel achieves it aim concisely, with an accessible and engaging style of writing throughout. Without a doubt, it is one of the best presented and most inspiring books about psychotherapy which I have ever read.

Book coverThe Case Against Psychotherapy Registration: A Conservation Issue for the Human Potential Movement
Richard Mowbray
Rating 4
Trans Marginal Press, London, 1995; ISBN 0952427001
Review published at, March 2006
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"[The author] draws evidence from wide-ranging sources which strongly suggests that most of the supposed benefits from the state regulation of therapy are unlikely to appear. In fact, he cogently argues that real losses are likely to accrue both to the public as a whole and to the field of psychotherapy in particular ... Suffice it to say that he has done the psychotherapy field a great service by researching and writing it. We should do ourselves a great favour and read it." - Joseph Griffin, The Therapist Vol 3 No 2, Summer 1995

In a nutshell, The Case (as it has become affectionately known) is a classic eye-opener - meticulously researched, cogently argued and clearly presented. Although published in 1995 and aimed at readers in the United Kingdom, Mowbray's book has a deep and continuing relevance to the practice of psychotherapy and counselling everywhere. Drawing sensibly on the substantial previous works of Daniel Hogan and Roberta Russell, and other wide-ranging sources, the author steadily and logically examines the evidence which supports or undermines the case for state licensing of practitioners and their activities. He considers both title and practice protection acts, giving examples from various countries.

Mowbray tells "a tale of flimsy historical underpinnings, professional and political shenanigans and vested interests" and raises many salient points, most of which have never been properly debated, never mind convincingly refuted. It is a shocking indictment of professional psychotherapy that so many minds have remained firmly closed to the very idea that there might be a case against the assumption that statutory regulation is a "good thing". The current situation (especially with the rekindling of regulatory plans in the UK) is better described by the story of the Emperor's New Clothes than any evidence-based scientific enquiry.

Mowbray concludes that a conventional licensing system (based on input parameters such as qualifications, length of training, and adherence to a school of therapy) is inappropriate and ineffective in protecting the public from harm. Also, he warns us about the likely ossification of psychotherapy practice, with "legitimized mediocrity" and excessively defensive practice prevailing. Obviously, the milieux in which therapists work in different countries vary considerably and Mowbray urges us to learn from the mistakes which have already been made elsewhere.

The Case is no rant: the author constructively explores alternative ways of serving the public interest, including more education, fuller disclosure from practitioners and applying existing legislation better. Inevitably, some of the legislative information in the book may now be a little outdated, but the arguments themselves are still as powerful today as they were a decade ago. Although not widely available, The Case is well worth seeking out as Richard Mowbray has provided us with a thought-provoking resource of great merit. Yes, it is an eye-opener, but for those honestly concerned with raising the integrity of our field, it is also a bit of a tear-jerker!

Book coverStop Blaming, Start Loving!: A solution-oriented approach to improving your relationship
Bill O'Hanlon & Pat Hudson
Rating 3.5
W W Norton, New York, 1996; ISBN 0393314618
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One of the most practical relationship self-help books I have ever come across. By taking a solution-oriented approach, it helps a couple shift the emphasis from analyzing the past to plotting the future. For couples used to loading up and firing the ammunition of past hurts and grudges, this approach will be challenging as it is very firmly focused on change and action. No more blaming, no more excuses - it makes each partner fully accountable to the other.

The book is written in an attractive and accessible style, with copious examples and real "nuts and bolts" relationship quandries. It is remarkable how hope and direction can be forged from despair when fresh viewpoints and creativity are harnessed. The authors are a couple themselves, and are highly experienced and respected therapists. They share their own personal stories, and those of friends and clients, to illustrate how love can evolve from blame. Highly recommended to any couple wanting to save their relationship, or even to those just needing to repair fences.

Book coverChanging for Good
James O Prochaska, John C Norcross & Carlo C DiClemente
Rating 3.5
Quill, New York, 1994; ISBN 038072572X
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Changing for Good is a self-help book par excellence. Unlike others, it does not confine itself to recommending action to alleviate a particular disorder or problem. Regardless of the individual's predicament and their readiness or reluctance to change, this work can help to progress and sustain the progress of therapeutic change. For example, the massive difficulties of chronic contemplators and relapsers are faced head on and managed decisively.

Although several schemes have been proposed to describe the stages and processes of change, none to date compares with the classification devised by these authors. By studying large groups of successful self-changers over a wide spectrum of problems, their work has been extensively validated and can predict future change with a high degree of accuracy. A key finding is that improvement is highly dependent on the processes of change being matched accurately to the individual's stage of change. This can certainly help therapists use their services more effectively and efficiently. Understandably, the authors' model of change has already been widely adopted by many public health and prevention programmes.

Whether used for client self-help or as a very readable reference for therapists, Changing for Good is an important, probably essential, contribution to the development of psychotherapy. By showing how significant the stage and processes of change are to outcome, it transcends the squabbles between different schools of therapy. This reflects the other research evidence that no single therapy is more "correct" than any other. Highly recommended reading.

Book coverFalling for Therapy: Psychotherapy from a Client's Point of View
Anna Sands
Rating 2
Macmillan, Basingstoke, 2000; ISBN 0333804309
Review published in Counselling in Scotland, June 2001
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Books written by clients of therapy are rare indeed and invariably, though understandably, reflect on a Bad Experience. Anna Sands's work is no exception, but it also offers valuable constructive criticism of therapy by comparing and contrasting the bad with a Good Experience (apologies to A A Milne). The potential for doing harm by failing to reconcile differing perceptions and agendas of therapist and client is vividly described.

As a "therapy virgin", Sands firstly attended a recommended psychodynamic therapist. Deteriorating to the point of breakdown, she finally terminated this damaging relationship and then worked long-term with another therapist whose approach was psychospiritual. Her first experience was "about crossed lines" and provides a chilling example of how an intelligent person (a teacher and author) can be gulled into suspending their common sense and intuition by professional status and theoretical dogma. "I was seduced. I had fallen for therapy and, as a result, my truth and my common sense too often took a back seat. Instead of rejecting ideas that felt out of place, I tried to find meaning in them." Her second period of therapy "did not entirely succeed in dissolving the hangover of unfinished business, but it was, I believe, a worthwhile experience ... What I cherish most is that our encounter was gracious, and it inspired me to strive to be gracious ..."

The author's reflections, reading and enquiry cover a wide range of issues germane to therapeutic practice, training and accountability. In particular, she challenges the tenets of Freudian theory and their relevance to a client's real life: "When one goes to a therapist, one needs clarity and support, and not the equivalent of a psychological quiz game entwined with an emotional endurance course." Perfectly reasonably, she asks why a therapy should feel unnatural, bypass common courtesy, eschew humour, or focus on pathology. "What happens if the guidelines which govern the relationship between practitioner and client take precedence over the ground rules about decent human behaviour? If they aren't one and the same, which rules does the client respect? Which reality does she suspend?"

When the author expressed her unhappiness about her first experience of therapy to the relevant professional organization, the United Kingdom Council for Psychotherapy, she was met with defensiveness and self-interest dressed as caring. Though she did not submit a formal complaint, professional barriers were raised to avoid liability and attribute difficulties to the client's perceptions of therapy. "In a profession based on honesty and truth, it all seems rather hypocritical. And how impartial, how neutral, can practitioners be when they are looking at the behaviour of someone who is a colleague, or even a personal friend?" Like many dissatisfied clients before her, Sands questions the ethics and very legitimacy of psychotherapy as a profession.

Sands's arguments are generally, sometimes exceptionally, well-articulated and stimulating. However, her relentless questioning style does become wearing and I found myself increasingly desperate to answer many of her questions - we certainly have sufficient evidence from research. A mention of the client's average 70% contribution to improvement would have been a good starting point. Another concern is the author's major focus on psychodynamic therapy. While contrasting this approach with that of her second therapist is illuminating, it restricts the view of the whole field of talk therapies. This creates two problems. First: the probability that a careless reader will extrapolate the critique of psychodynamic therapy to psychotherapy in general (and, of course, from psychodynamic therapists to psychotherapists in general). Second: by arguing within Freudian concepts and terminology she may be inadvertently lending credibility to the psychodynamic model and weakening her own case.

The author did not write this book for any particular readership, hoping that both clients and practitioners might benefit. Open-minded therapists, and especially psychodynamic ones, can certainly learn from this client's feedback. (When reading about the goings-on, most therapists will no doubt insist: "I would never do that.") But, without some distillation of the arguments and summarizing as the book progresses, I am less certain what past, present and intending clients will make of it. There is quite a lot of scope for confusion. Lay readers may find it particularly difficult to differentiate between the failure of the therapist and the failure of the therapeutic approach.

Despite these reservations, I would encourage practitioners to read this book, and, if the shoe fits, to be humbled by a client's viewpoint: "When arrogance and insensitivity are apparent in the work of therapists it is, because of the nature of their profession, particularly chilling. When we put our trust in someone, they inhabit a position of privilege, and to marginalise the importance of courtesy, tenderness and compassion can rarely be justified. The emotional distance that training may engender can become precisely that which prevents a climate of true understanding ... From the client's point of view, to be asked occasionally 'Are you finding what we are doing helpful?' might open doors that had felt closed." Falling for Therapy provides a powerful reminder of the need for much better public information about what really makes therapy effective and therapists behave ethically.

Book coverClinical Supervision Made Easy: The 3-step method
Els van Ooijen
Rating 2.5
Churchill Livingstone, London, 2003; ISBN 0443072426
Review published in Ipnosis No 13, Spring 2004
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The professional institutionalisation and pyramid-selling of formal therapist supervision have continued apace for some years, without any compelling evidence of supervision's efficacy or efficiency in improving client outcomes. So, those of you who know me and my work may be surprised at me agreeing to review a book entitled Clinical Supervision Made Easy. However, even as a sceptic about current trends in supervision, I can hardly disagree with these words from Els van Ooijen's Conclusion: "Supervision implies a willingness to let go of the tight hold we have over our own current vision and being open to let in some other possibilities. The effect is a view or vision that has expanded." Starting from this common-sense basis, I am happy to explore the possibility that this volume might shed more light on the true therapeutic worth of 'clinical supervision'.

To begin, I will lay aside issues intrinsic to supervision itself and focus on giving you a feel for van Ooijen's work. Clinical Supervision Made Easy is sensibly and attractively laid out, with devices such as graphics, 'Thinking Points' and 'Questions for further reflection' used to provide appropriate diversions from the text. The author's style of writing should be accessible to a wide range of practitioners in the therapeutic and caring fields, being relatively unpretentious and personal enough to build good rapport with the average reader. (Regretably though, some jargon such as "helicopter skills", "co-creation of meaning" and the ubiquitous "stuckness" does creep in.)

After reviewing other models of clinical supervision and laying some groundwork on attitudes, attributes and contracts, the author's '3-Step' method of supervision is introduced and developed logically. She illustrates its practical application with sufficient realistic examples and supervision session transcripts. The last quarter of the book is devoted to discussing how the 3-Step method can be applied to group supervision, and how it can inform ethical decision-making, management and leadership.

To satisfy your curiosity, van Ooijen's 3 steps are:

  1. What do I need to know? (focus on facts)
  2. How am I going to find out? (focus on feelings)
  3. What will I do now that I have found out what I wanted to know? (focus on action)

Her approach to supervision is billed as "not linked to any particular model, theoretical orientation or profession ... it can be used in any helping context, irrespective of the actual profession of the worker. Together the three steps constitute a framework or structure for a session as well as a step-by-step guide on how to run it."

Throughout the book, the author has taken care to anticipate and discuss many of the snags, challenges and human foibles which bedevil supervisory work in the real world. This attention to practical detail is commendable and will probably prove to be one of the book's main selling points over more theoretical texts. Parts of the discussion on the emotional and unconscious aspects of our minds should be updated to integrate our current best research findings on emotions and dreams. And whatever happened to the role of humour in the creative process?

Having warmed to several aspects of van Ooijen's writing, it seems a bit churlish but absolutely necessary to look more critically at the contribution it makes to our field. The 3-Step method may be "characterised by openness and flexibility", but it is hardly original or particularly insightful. For example, Driscoll's Reflective Cycle of "What?", "So what?" and "Now what?" seems remarkably similar. (I am tempted to add "And who did/will do what?" to clarify roles!) However, if the structure and focus which the 3-Step method provides appeals to a supervisor, their supervisee is certainly likely to benefit, by analogy to therapy itself.

For observers of the Dodo Bird Effect*, it is particularly interesting to compare the author's early statement that "[t]he relationship between supervisor and supervisee is the most important aspect of supervision" with the final statement that "supervision is rapidly becoming an activity in its own right, with its own models, skills, methods and techniques." Like many authors before her, van Ouijen presumes that formal therapy supervision is generally A Good Thing, without objectively reviewing the evidence first. Also, the importance of gaining direct feedback on process and outcome from the client to adjust the ongoing therapeutic approach is sadly neglected. But at least, the author acknowledges and attempts to address the messy overlap of activities and roles involved in supervision.

Overall, I enjoyed reading Clinical Supervision Made Easy and it deserves a place on the therapy bookshelf. However, the paradoxes concerning therapy supervision and the suspicion that it is often a professional palaver taken too far remain relatively unscathed.

*The Dodo Bird Effect refers to the overwhelming finding from psychotherapy research that there is a general equivalence of outcomes, regardless of the models and techniques used by particular therapeutic approaches.

Book coverThe Great Psychotherapy Debate: Models, Methods, and Findings
Bruce E Wampold
Rating 4
Lawrence Erlbaum Associates, New Jersey, 2001; ISBN 0805832025
Review published in Ipnosis No 8, Winter 2002
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Readers may be very interested in the book The Great Psychotherapy Debate by Bruce Wampold which seems to have escaped the notice of many European reviewers. This book presents possibly the best scientific analysis of psychotherapy ever written, and its implications for the field are profound. The author has comprehensively reviewed the corpus of research evidence to dispute the medical model's view that the benefits of psychotherapy derive from the specific ingredients contained in a given treatment. The evidence overwhelmingly supports the hypothesis that psychotherapy works mostly through general therapeutic effects, best described by a contextual model.

The idea that general or common factors are primarily responsible for the efficacy of psychotherapy is not new (being first mooted by Saul Rosenzweig in 1936 and notably by Frank & Frank later), but Wampold's work provides it with an empirically validated foundation like never before. With scrupulous care and objectivity, the author has reviewed the data on the absolute efficacy of psychotherapy, the relative efficacy of treatments, the specificity of ingredients contained in various therapies, effects due to common factors such as the therapeutic alliance, therapist allegiance and adherence to treatment protocol, and effects produced by different therapists. For each aspect, the evidence clearly corroborates a contextual model and disconfirms the dominant medical model metaphor for psychotherapy. In addition, Wampold discusses how the two models compete on a theoretical level and explains in detail the rules for the acceptance and presentation of evidence and the usefulness of meta-analyses. The quality of the reasoning and the logical layout of chapters and text are commendable.

Amidst a wealth of research results, I found it interesting to note that the specific ingredients of the currently favoured cognitive-behavioural treatments for depression and anxiety are apparently not responsible for the benefits of these treatments. Adherence to treatment protocol was not found to be generally associated with outcome, but allegiance effects (where the therapist is enthusiastic about the efficacy of a treatment) are consistently present and large.

The final chapter of The Great Psychotherapy Debate discusses the implications of the research findings and makes significant recommendations regarding research, practice, training, and the provision of psychotherapy services. One important scientifically derived conclusion is that the variation in psychotherapy outcome can be partitioned thus: at least 70 percent of psychotherapeutic effects are general effects (due to common factors underlying all psychotherapies); at most 8 percent are specific effects (due to the specific ingredients of a given treatment); and the remaining 22 percent variability is unexplained, but is certainly due in part to client differences. A shift in emphasis in research and training should reflect the relative importance of these effects.

Wampold concludes about techniques: "The evidence in this book has shown that specific ingredients are not active in and of themselves. Therapists need to realize that the specific ingredients are necessary but active only in the sense that they are a component of the healing context. Slavish adherence to a theoretical protocol and maniacal promotion of a single theoretical approach are utterly in opposition to science. Therapists need to have a healthy sense of humility with regard to the techniques they use." Also, the data show that far more variation of outcome is due to therapists within a treatment than to treatments. Defining therapist competence by the quality of their outcomes is recommended.

The Great Psychotherapy Debate is a serious, scientific read and some readers looking for enlightening clinical anecdotes or individual case studies will no doubt find its strictly factual and statistical presentation too dry for their taste. Nevertheless, I would recommend this book to any reader interested in evidence-based practice, training or policy-making for the provision, funding and regulation of psychotherapy services. Regarding the current dominance of the medical model and the current vogue for "empirically supported" psychological treatments, Wampold warns us: "Therapy practice is both a science and an art ... Treating clients as if they were medical patients receiving mandated treatments conducted with manuals will stifle the artistry."


Disclaimer: This website only provides general information derived from research findings. It is not a substitute for a consultation with a mental health professional about an individual case. While every effort is made to ensure the accuracy and objectivity of information on this site, the authors accept no responsibility for the consequences of errors or omissions. Information about the practice of psychotherapy and counselling in the United Kingdom and/or Scotland may not be applicable in other countries. External websites are linked in good faith, but their contents cannot be vouched for.

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