III: Clinical Theories and Therapeutic Action

Everything factual is already theory... .The blueness of the sky reveals the basic law of chromatics. Don’t go looking for anything beyond phenomena: they are themselves what they teach.

-Goethe

Over the last three decades clinical scholars have come to appreciate the strengths and limitations of different approaches developed within the foundational schools of thought, exploring shared concerns and points of emphasis, and practitioners continue to combine ideas and methods from a range of perspectives in their efforts to expand concepts of therapeutic action and strengthen the outcomes of help and care. Thinkers have drawn on psychodynamic, behavioral, cognitive, and humanistic paradigms in fashioning integrative models of practice.

By way of example, Marsha Linehan joined behavioral and cognitive approaches with relational concepts and Buddhist mindfulness practices in developing her influential model of dialectical behavior therapy (Linehan, 1993). William Miller bridged the person-centered perspective of Carl Rogers and cognitive-behavioral methods in shaping his conceptions of motivational interviewing (Miller & Rollnick, 2012). Paul Wachtel continues to develop a pragmatic approach that links core concepts in relational psychoanalysis with behavioral, cognitive, experiential, and systemic perspectives, extending earlier integrations of psychoanalytic ideas and behavioral therapy (Wachtel, 2014).

I strongly support efforts to deepen our understanding of core processes believed to operate across the major schools of thought and to combine concepts and methods in practical, flexible approaches to help and care. In following the principles of clinical pragmatism, as we have seen, we consider the contributions of our “purist” thinkers and models of practice selectively in light of the particular needs of the clinical situation, joining ideas and methods from divergent perspectives that would be considered incompatible in more idealized renderings of the therapeutic endeavor.

In accord with the pluralist orientation of clinical pragmatism, however, it is crucial to preserve the distinct identities of the foundational schools of thought and to develop an appreciation of the concerns and values that influence different ways of seeing, understanding, and acting. A range of intellectual traditions and philosophical perspectives have shaped our paradigms of therapeutic action. Our classical behavioral approaches originate in positivist conceptions of science, for example, while humanistic perspectives are closely linked with phenomenology. Although the earliest versions of cognitive therapy emphasized notions of rationality and objective truth, contemporary models of practice draw largely on constructivism, postmodern thought, and the science of mind. In light of fundamental philosophical differences our theories of psychotherapy are incommensurable, operating as distinct systems of thought that cannot be integrated.

The foundational schools of psychotherapy set forth compelling accounts of the human situation, focusing our attention on overlapping realms of

Clinical Theories and Therapeutic Action 69 experience from different points of view, introducing a variety of root metaphors, values, concerns, purposes, models, and methods that influence what we say and do in the clinical situation. If each paradigm fails to capture the varieties and complexities of our experience, all are crucial because they propose different ways of attending, understanding, and acting, helping us appreciate the implications of divergent ideas by pressing them to their limits.

Without a solid grounding in the theories of psychotherapy, I argued in the introduction, we risk the dogmatic embrace of a single paradigm, a willy-nilly eclecticism, or reductive, mechanized approaches to treatment by protocol, lacking conceptual foundations for critical thinking as we negotiate the complexities and ambiguities of the clinical situation, failing to understand the elements we are trying to integrate and why.

In the third part of the book we explore orienting perspectives and concepts of therapeutic action that shape understanding and practice in the psychodynamic, behavioral, cognitive, and humanistic schools of thought. In doing so, we trace the evolution of therapeutic practice in each paradigm and consider the ways in which recent developments in the science of mind have deepened our understanding of core processes believed to facilitate change and growth in accord with the principles and values of clinical pragmatism. As we approach our therapeutic practice from a pragmatic point of view, we come to appreciate the distinctive features of different orientations, shared concerns, and basic principles of help and care that often remain obscured by ideological differences, parochialism, and factionalism among the different schools of thought.

Given the influence of psychoanalysis in the development of theory and practice across the paradigms of psychotherapy, I begin Part III with an account of the psychodynamic tradition. In Chapter 4 I focus on the depth psychologies of Sigmund Freud and C. G. Jung. In Chapter 5 I trace the emergence of relational perspectives in contemporary psychoanalysis. I continue with reviews of the behavioral, cognitive, and humanistic traditions in Chapters 6-8. In Chapter 9 I present two cases and consider the ways in which orienting perspectives in the foundational schools of thought, neuroscience, and clinical pragmatism strengthen our understanding of essential concerns in therapeutic action.

References

Goethe, J. W. (1829/1998). Maxims and reflections, P. Hutchinson (Ed.), Elisabeth

Stopp (Trans.). London: Penguin.

Linehan, M. (1993). Cognitive treatment of borderline personality disorder. New York: Guilford.

Miller, W. & Rollnick, S. (2012). Motivational interviewing: Helping people change, 3rd edn. New York: Guilford.

Wachtel, P. (2014). Cyclical psychodynamics and the contextual self New York: Routledge.

 
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