Expectation E-Book

Rubin Battino

• Herausgeber: Crown House Publishing
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 287

Veröffentlichungsjahr: 2006

Beschreibung

It is the author's contention that creating an environment where the client expects change is the foundation of doing effective very brief therapy. His own private practice is one where he rarely sees clients more than one or two times. Clients know in advance that this is the way that he works, and so their expectation is that during this session they are going to get down to the hard stuff. This means working as if each session were the last one. So, this book is about all of the things that are designed to work in a single-session mode.

Leseprobe

Expectation

The Very Brief Therapy Book

Rubin Battino

MS, Mental Health Counseling Adjunct Professor, Department of Human Services (Counseling) Wright State University

Acknowledgments

The author and publisher gratefully acknowledge the permission granted to reproduce copyright material in this book (exact citations given throughout the text) from the following sources:

American Psychological Association

Excerpts from The heart & soul of change: What works in therapy by M. A. Hubble, B. L. Duncan and S. D. Miller (eds) are copyright © 1999 by the American Psychological Association. Reprinted with permission.

Brunner/Mazel (Taylor & Francis Group)

All excerpts in Chapter 12 are copyright © 1998 from Nature-guided therapy: Brief integrative strategies for health and well-being by G. W. Burns. Reproduced by permission of Routledge/Taylor & Francis Group, LLC.

All excerpts in Chapter 11 are copyright © 1986 from Enchantment and intervention in family therapy: Training in Ericksonian approaches by S. R. Lankton and C. H. Lankton. Reproduced by permission of Routledge/Taylor & Francis Group, LLC.

Crown House Publishing Limited

Battino, R., 2002, Metaphoria: Metaphor and guided metaphor for psychotherapy and healing. Carmarthen, UK: Crown House Publishing.

Battino, R., and South, T. L., 2005, Ericksonian approaches: A comprehensive manual. (2nd edn.). Carmarthen, UK: Crown House Publishing.

Bodenhamer, B. G., and Hall, L. M., 1999, The user’s manual for the brain: The complete manual for neuro-linguistic programming practitioner certification. Carmarthen, UK: Crown House Publishing.

Derks, L., 2005, Social panoramas: Changing the unconscious landscape with NLP and psychotherapy. Carmarthen, UK: Crown House Publishing.

Hall, L. M., and Bodenhamer, B. G., 2003, The user’s manual for the brain Volume II: Mastering systemic NLP. Carmarthen, UK: Crown House Publishing.

Kane, S., and Olness, K. (eds), 2004, The art of therapeutic communication: The collected works of Kay F. Thompson. Carmarthen, UK: Crown House Publishing.

Ernest Rossi Rossi, E. L., 1996, The symptom path to enlightenment: The new dynamics of self-organization in hypnotherapy: An advanced manual for beginners. Pacific Palisades, CA: Palisades Gateway Publishing.

John Wiley & Sons, Inc. Excerpts from The heroic client: A revolutionary way to improve effectiveness through client-directed, outcome-informed therapy are copyright © 2004 B. L. Duncan, S. D. Miller and J. A. Sparks. Reprinted with permission of John Wiley & Sons, Inc.

Excerpts from Single-session therapy: Maximizing the effect of the first (and often only) therapeutic encounter are copyright ©1990 M. Talmon. Reprinted with permission of John Wiley & Sons, Inc.

Lawrence Erlbaum Associates, Inc. Wampold, B. E., 2001, The great psychotherapy debate: Models, methods and findings. Mahwah, NJ: Lawrence Erlbaum Associates, Publishers.

W. W. Norton & Company Excerpts from The miracle method: A radically new approach to problem drinking by Scott D. Miller and Insoo Kim Berg. Copyright © 1995 by Scott D. Miller and Insoo Kim Berg. Used by permission of W. W. Norton & Company, Inc.

Excerpts from My voice will go with you: The teaching tales of Milton H. Erickson by Milton H. Erickson and Sidney Rosen, M.D. Copyright © 1982 by Sidney Rosen, M.D. Used by permission of W. W. Norton & Company, Inc.

Excerpts from A guide to inclusive therapy: 26 methods of respectful, resistance-dissolving therapy by Bill O’Hanlon. Copyright © 2003 by Bill O’Hanlon. Used by permission of W. W. Norton & Company, Inc.

Every effort has been made to trace copyright holders and to obtain their permission for the use of copyright material. The author and publisher apologize for any errors or omission and would be grateful if notified ot any corrections that should be incorporated in future reprints or editions of this book.

Contents

Title Page

Acknowledgments

Foreword: Long Days Journey into Light by Scott D. Miller, PhD

Introduction

Chapter 1 Introduction to Very Brief Therapy

1.1 Introduction

1.2 The Great Psychotherapy Debate

1.2.1 Five Components of the Medical Model

1.3 The Heart and Soul of Change

1.4 Duncan, Miller and Sparks’s “Heroic Client”

1.4.1 The Outcome Rating Scale

1.4.2 The Session Rating Scale

1.5 Moshe Talmon’s Single Session Therapy (SST)

1.6 Some Concluding Comments

Chapter 2 Expectation and As-If

2.1 Importance of Expectation, Motivation and As-If

2.2 The Theory of Change

2.3 The Power of As-If

2.4 Reframing

2.5 Summing Up

Chapter 3 Rapport

3.1 Importance of Rapport

3.2 Rapport-building Skills

3.2.1 Linguistic or Verbal Pacing

3.2.2 Physical or Postural Pacing

Chapter 4 Language for Very Brief Therapy

4.1 Hypnotic Language

4.2 Expectational Language—Suggestions, Implications and Presuppositions

4.3 Torpedo Style Language

4.4 Metaphoric Language

4.5 Summing Up

Chapter 5 Hypnosis and Very Brief Therapy

5.1 Rationale for Using Hypnosis

5.2 Metaphor and Hypnosis

5.3 Hypnosis in Various Therapies

Chapter 6 Solution-Oriented Approaches

6.1 The Work of de Shazer and Associates

6.2 Miller and Duncan and Colleagues’ Approaches

6.3 Berg and Dolan and Miller’s Wisdom

6.4 Common Sense

Chapter 7 Bill O’Hanlon’s Approaches

7.1 Inclusive Therapy

7.2 Brief, Respectful Therapy

7.3 Hypnosis in O’Hanlon’s Work

Chapter 8 Lucas Derks’s Social Panorama

8.1 Introduction

8.2 Some Examples of Social Panoramas

8.3 Summing Up

Chapter 9 Erickson and Very Brief Therapy

9.1 Utilization Principle

9.2 Practicality

9.3 Stories and Metaphors

9.4 Tasks and Ordeals

Chapter 10 Jay Haley and Ordeal Therapy

10.1 What is Ordeal Therapy?

10.2 Haley’s Systematics of Ordeal Therapy

10.3 Examples of Ordeals

Chapter 11 Ambiguous Function Assignments

11.1 Description of Ambiguous Function Assignments

11.2 Some Suggestions for Ambiguous Function Assignments

Chapter 12 Burns’s Nature-Guided Therapy

12.1 What is Nature-Guided Therapy?

12.2 Some Ecotherapy Procedures and Examples

12.3 Nature Heals

Chapter 13 Metaphoric Approaches

13.1 Uses of Metaphor

13.2 Richard R. Kopp’s Metaphor Therapy

13.2.1 Client-generated Metaphors for Immediate Concerns

13.2.2 Transforming the Early-memory Metaphor

13.3 Guided Metaphor

Chapter 14 Rossi’s Rapid Methods

14.1 Fail-safe Methods

14.2 Ideodynamic Methods (mostly D. B. Cheek)

14.3 Some Concluding Comments

Chapter 15 NLP Approaches

15.1 The NLP Meta-model of Language

15.1.1 Distortions

15.1.2 Generalizations

15.1.3 Deletions

15.2 The “Swish” Method

15.3 Time Line Therapy

15.4 V-K Dissociation

15.5 Reframing the NLP Way

15.6 Changing Personal History

15.7 Summing Up

Chapter 16 Narrative Therapy

16.1 Introduction

16.2 Some Elements of Narrative Therapy

16.3 Summing Up

Chapter 17 Rituals and Ceremonies

17.1 Introduction

17.2 Psychotherapeutic Uses of Ceremonies

Chapter 18 When All Else Fails

Ask the Client

Listen

Minimalism

Crystal Ball

Metaphors

Ambiguous Function Assignments

Look at Yourself From

Provocative Therapy

Refer/Consult

Chapter 19 Brief Final Thoughts

19.1 The Universal Very Brief Therapy Intervention (UVBTI)

References

Index

Copyright

Foreword

Long Days Journey into Light

Reading Rubin Battino’s book Expectation: The Very Brief TherapyBook brought to mind a personal experience regarding the potential impact of brief therapeutic encounters. Some twenty years ago, I was a graduate student, plodding through my remaining classes, conducting dissertation research, while struggling to make ends meet through a combination of student loans and a graduate assistantship. I was also several years into my own psychoanalysis. Three and sometimes four times a week, I drove the ten-mile stretch from the University to my analyst’s office. Once there, I waited patiently in the anteroom listening to classic music until my analyst would appear and invite me into the salon.

The nature of the treatment had not changed for several years. I would lie on a couch, my head resting on a clean white linen napkin neatly laid out following the last patient. Then I would talk: about my family, my childhood, school, my marriage, my dreams and, of course, my fantasies. Meanwhile, my analyst—a graying, grandfatherly kind of fellow trained in the Winnicot School—sat behind me, chin in hand with one leg crossed at the knee (I know because I almost always found a reason to sit up once a session to look at him for a response or add emphasis to what I was saying).

At some point during this process, I’d started keeping a dream journal. Desperately hoping to be a “good” and cooperative patient, I left nothing out. As a result, the collection of spiral bound notebooks containing lengthy recollections or mere fragments grew tremendously over time. And while I was (and still am) not an artistic person, I even started sketching my dreams, bringing them to my sessions and, in my spare time, arranging and re-arranging the drawings in an attempt to plumb the darker recesses of my unconscious.

Originally, I’d entered analysis as a way of bolstering my experience and knowledge about treatment. I was not depressed or anxious and both my upbringing and life experience were more akin to Leave it to Beaver than say, Nightmare on Elm Street. But I was a young graduate student—younger and less experienced than most of the others in my cohort. Nearly all of the students in my class, for example, either were or had been in therapy. A significant number were already working in the field. Alas, I felt the need to “catch up,” and do so with alacrity. Psychoanalysis seemed to fit the bill. What’s more, the rigorous, driven, “leave no stone unturned” quality of the approach appealed to me personally.

Several years into the experience, however, I became depressed—so much so that the number of times per week I went to therapy was stepped up and I started taking anti-depressant medication. The almost limitless enthusiasm I’d had for life and learning drained away. It was all I could do to make it to classes and work. I became increasingly isolated, rarely interacting more than was necessary with schoolmates or work associates. When my marriage finally started to unravel, I found myself struggling daily with thoughts I’d never had before: I wanted to be dead.

It was around this time that I had a life-changing experience. The incident was neither planned nor expected, but I believe it did save my life. As part of my work as a graduate assistant, I helped with the planning and organization of continuing education events for the local chapter of a national professional organization. The work wasn’t particularly glamorous—mostly, I pasted mailing labels on brochures and collated them for bulk-rate shipping—but I was, as a result, able to attend trainings featuring cutting-edge practitioners and researchers without having to pay the price of admission.

As fate would have it, I attended a two-day workshop on the subject of brief therapy. I listened attentively to the presenter whose style was not only entertaining and engaging but his message quite provocative: effective therapy could be and was, in most instances, relatively short in duration. I learned about Milton H. Erickson, Jay Haley, and the Mental Research Institute (MRI). Videotape of real sessions and role plays with audience members were used to demonstrate various principles and practices. And while the details of those two days are now a blur, I remember coming away from the experience with a profound appreciation of the role that language and expectation play in the process of change.

By the end of the two days, I’d decided to contact the presenter for help. Being a compulsive person, my idea was to get enough “brief therapy” to resolve my depression so that I could finish my analysis. Although the setting was quite different—I had to sit in a waiting room full of other people seeking help in a rather sterile-looking professional office building located in what amounted to a strip mall—the hour long session did not strike me as all that remarkable. We sat face-to-face, the therapist listened attentively and asked lots of questions. Near the end of the interview, he took what he called a “break”, leaving the room temporarily, he said, “to reflect on the visit and collect his thoughts” before making some suggestions.

I was writing a check for the hour when he returned. “I’ve given this some thought,” he said, “and have an idea.”

“Great,” I either said or thought. “Let’s hear it.”

“Are you interested?” he asked.

“Yeah,” I said with a pained laugh. “Of course.”

“Because,” he then continued, “you’ve got a lot going on right now, and I don’t want to burden you.”

“I’m interested, really … anything you can tell me,” I said. “… I’m drowning here.”

“With everything that’s going on, this may sound a little odd, though, even crazy.”

Not being sure I understood, I shook my head and then said, “I’ve got to do something.”

“OK, then,” he continued, “here it is. When you go to work tomorrow, to your office, I’d like you to go over to the window near your desk and roll the blinds open … or, if you are tempted, pull the shades up completely.”

I must have stared blankly at him for more than a few seconds because he soon asked me if I’d understood him and then, even though I’d said I had, he repeated the very same instructions once or twice more. But what perhaps appeared to him as incoherence on my part was actually shock. “Of course, I heard it,” I thought privately to myself. “I’m not an idiot. I’m an advanced, doctoral-level graduate student.” What I wanted to do was shout, “That’s it? Roll up the Blinds? Pull up the Shades? That cost 90 bucks? Geez.”

That night doom accompanied and intensified my usual gloom. Something was different that’s for sure. I was mad or, given the current company of readers better said, angry. I felt cheated. Graduate school wasn’t teaching me anything I could use to help myself. I’d now spent years talking about my mother, my dreams, fantasies and so on—all to no avail. And now, this guy tells me to pull up my shades. “Our profession sucks!” I thought as I prepared for and then went to bed.

The next morning, I drove into the city, fighting traffic while brooding over the previous day’s events. In my memory, I picture other drivers catching a glimpse of me complete with a cartoon-like bubble hanging over my head with “&%$#!” written visibly inside. My mood would certainly have been obvious to anyone who watched me exit my car that day and stomp up the walkway to my office. Sitting down, I followed my usual routine. I turned on the low wattage light fixture that sat on my desk, leaned back in my chair and began looking over the series of hand-drawn dream images currently hanging on the wall.

My attempt to wring some life-changing insight out of my dreams kept being interrupted by thoughts about the previous day. Every now and then I’d turn toward the Levelor® blinds covering the window adjacent to my desk. Rolling my eyes, I’d think, “Pull up the shades, ha! What humbug.” Eventually, however, I thought, “Ah, what the heck,” and reached out, grabbed the rod next to the shades, and began turning. Immediately, light came flooding into the office. I watched transfixed as people walked the pathways around and into the building—sometimes alone, often in pairs, thinking, laughing, being, eating and talking. Birds flitted from tree to tree. Squirrels chased each other or perched high on tree limbs nibbling some newly found treasure. And when I spontaneously cranked open the office window, the sounds of this life happening outside the narrow confines of my office filled the room.

Suffice it to say, the experience was “eye opening”. In the weeks following, I spent more and more time looking outward rather than inward. My energy quickly returned and the depression disappeared. Beyond the impact on my personal wellbeing, however, that very brief encounter—a single session—actually changed the direction of my entire career. Of course, following my experience, I wanted to know, “How did he know to do that?” Together with my colleagues, I’ve spent the last 20 years writing about and conducting research on the qualities of effective therapy and therapists.

Much of what we and others have found, and more, is collected, summarized, and illustrated in this concise, clearly written volume by Rubin Battino. The book reflects his knowledge and experience assembled over many years of clinical practice in a real-world clinical setting. As such, it is a treasure. Moreover, in addition to providing specific ideas and strategies for helping clients, it provides a platform for raising the hopes of clinicians working during a time in the history of the field when more is expected for less. Take the book, find yourself a comfortable chair next to a window, pull up the blinds, and expect to change.

Scott D. Miller, PhD Chicago, Illinois www.talkingcure.com

Introduction

A number of years ago, I heard an impressive talk by the psychologist Moshe Talmon on single-session therapy. I even had the privilege of spending some time chatting with him over a meal. His book on the subject (1990) and the talk contain three startling revelations about the process of doing psychotherapy. Talmon did the unusual thing of studying the records of the large health maintenance organization he worked for. His first discovery was that the most common number of sessions for the large number of clients the psychotherapy staff saw was one. The second revelation was that there was no apparent connection between the orientation of the therapist, i.e., the type of psychotherapy they used in their practice, or with a particular therapist. That is, the modal length of therapy for every one of the therapists was a single session. Moreover, thirty per cent of the patients chose to come for only one session in the period of one year. (I will be writing more later about the research that shows that the therapist’s orientation has little to do with outcome.) The third revelation had to do with follow-up phone calls by neutral staff members. The patients were asked if they were satisfied with the therapy they received. Then they were asked to tell the caller what it was that the therapist did that was so helpful. Independently, the therapists were asked to consult their case notes (this is six months to one year later) and to relate what it was that they thought they did in the session that was helpful to the client. Again, in the judgment of the therapist, what had they done that was critical in helping the client? You may or may not be surprised to discover that there was essentially zero correlation between what the client said helped them and what the therapist thought was important! A reasonable conclusion from this is that it is the client’s expectations and attitude that are the important elements of successful therapy.

This brings me to the subject of this book. It is simply how I work as a very brief therapist. My hope is that you will learn some useful ways of working fast and effectively. By “very brief” I mean that I rarely see my clients more than one or two times—usually it is just once. (They do know that I will see them as many times as they feel that meeting with me will be helpful.) I do get feedback sporadically, and it has been uniformly positive. It is my expectation that each session is the last one, and that generally one session is all that is needed. Of course, working for myself, my sessions are always open-ended and can last a long time. That is, there is no time constraint on a session. Given my expectation and belief in a single session, it is natural that the client accepts this, and that the session is full of meaningful work for the client. My intake form is quite simple, I do not do testing or diagnoses, and we get right down to work. As a related illustration, I recall some comments the psychologist Joseph Barber made about working with clients who have migraines. In effect, he tells them that their body already knows how to stop the migraine because it invariably does so after some period of time. Since this is invariably the case, the client must agree with this statement. Barber’s question (and suggestion) to the client is, “Since your body already knows how to end the migraine, why wait one, two, or three days to do this when you can actually do it in the next hour, or even the next few minutes?” Change the frame and change the expectation. So, throughout this book, the idea of “expectation” will be prominently featured.

Chapter 1 is not only an introduction to the book and the idea of doing very brief therapy, but it is also a summary of significant research on this subject. In particular, the work of Miller, Duncan, Hubble and associates, and that of Wampold will be highlighted. What has emerged from their research is evidence supporting what I cited above as Talmon’s “revelations”. In effect, the clients and their attitudes and expectations are the central key to all psychotherapeutic work. I will be writing more about this later, yet I must insert here the bit of wisdom some group leader in my early training gave, “When all else fails, ask the client what will work.” Perhaps, this should be done before “all else fails”!

In Chapter 2, I discuss the ideas of expectation as applied to psychotherapy, and also the power of As-If. Also covered are the theory of change and reframing. The therapeutic alliance has been written and spoken about as being central to change work, so Chapter 3 briefly covers rapport-building skills. That is, it is useful if the client believes that you both exist in the world in somehow and somewhat similar ways.

Being restricted to “talk” therapy by not being a physician means that the psychotherapist needs to rely on language to help a client find ways to change. Chapter 4, then, is a short introduction to language usage for doing very brief therapy (NLP Meta-model of language is discussed in Chapter 15). Since hypnosis can be a powerful adjunct to therapeutic work, Chapter 5 recounts the ways in which hypnosis can be used expectationally for change work. Recall that any procedure that asks a client to go “inside” involves some level of trance.

The solution-oriented approaches developed by Steve de Shazer and his associates are quite useful for rapid change work. The “miracle question” and its variants are effective. This is covered in Chapter 6. Bill O’Hanlon’s approaches are discussed in Chapter 7, and they include his “brief, respectful approaches”, inclusive therapy and hypnotic work.

Derks’s Social Panorama work can be effective in interesting ways by incorporating the client’s images about their social environment. This is presented in Chapter 8. Milton H. Erickson was a pioneer in the area of very brief therapy. His Utilization Principle is a guideline for involving who the client is in organizing a session. The client is central to a session, and it has been said of Erickson that he devised a new approach to fit each client. Chapter 9 discusses Erickson’s methods of working briefly, although, if you study his cases you will find that he was flexible in the number of sessions for any given client. Erickson’s sessions were also open-ended.

Two approaches derived from Erickson’s work, and then extensively developed further, are “Ordeal Therapy” as practiced by Jay Haley (Chapter 10), and “Ambiguous Function Assignments” as systematized by the Lanktons (Chapter 11). Burns has developed an approach that involves interaction with Nature, and which he calls “Nature-Guided Therapy” or “Ecotherapy”. This is covered in Chapter 12.

Metaphoric approaches have been used in many ways by many practitioners. Erickson was a master of metaphor. In addition to discussing classical metaphoric work, Chapter 13 provides information on R. R. Kopp’s “Metaphor Therapy”, and Battino’s “Guided Metaphor”.

Over the years, E. L. Rossi has developed a number of rapid methods for doing therapy. He describes some of them as “fail-safe”, others as polarity approaches, and is a master on minimalism in working with a client. Rossi’s work is described in Chapter 14.

Neurolinguistic Programming (NLP) has been prolific in developing many ways of doing brief therapy. Some of these methods will be described in Chapter 15. “Narrative Therapy” as developed by Epston and White has the client’s life story and the client as central to change work. The principles and practice of their work is the subject of Chapter 16. Rituals and ceremonies are discussed in Chapter 17.

Finally, there are some “when all else fails” comments by way of summary in Chapter 18. At the core of the author’s way of doing very brief therapy is his expectation that it is possible and practical and learnable. Why not?

Chapter 1

Introduction to Very Brief Therapy

1.1Introduction

My introduction to brief therapy came from examining the literature on the subject a number of years ago. I was intrigued by finding a book that was enthusiastic about brief therapy being conducted in one year (rather than five or more), and in under fifty sessions (rather than hundreds). The book, of course, was psychodynamically oriented. In recent times, “brief” has come to mean something like six to twelve sessions, much of this mandated by managed care systems. In fact, many of these managed care systems will tie a number of sessions to a particular diagnosis. This is carrying the intrusion of the medical model into psychotherapy to what I consider to be ridiculous extremes, so I am being explicit about this at the outset of this book. The medical model works well when prescribing a particular drug for a specific infection for a set number of days. But people who seek the help of psychotherapists are not diseased, they are troubled and stuck and seek some guidance for their unique concerns. A diagnosis such as “depression” is manifested uniquely by each person, and their individuality and history must be taken into account in any work done with them. It is in this sense that Milton H. Erickson’s Utilization Principle is primary in determining how you work with a client. This principle simply states that every client is absolutely unique, and that the treatment needs to be specific to that client (and not some abstract diagnosis). The client’s uniqueness is utilized in working with them.

I came to the central theme of this book via something I heard Steve de Shazer report in one of his presentations. This was about the results of a study they carried out at the Brief Therapy Family Center of Milwaukee. The receptionist was told to randomly tell each new client, after looking at their intake form, that their particular concern usually took five or ten sessions. The center’s staff did not know what the client was told. Later analysis showed that the five session clients started doing significant work around the fourth session, and that the ten session clients started doing significant work around the eighth or ninth session. In essence, the clients were told when to expect change to begin, and they responded appropriately. My reasoning then was, why wait for the fourth or eighth session, why not have the expectation be that significant work can be done in the first session and, further, why not imply that one session was all that was usually necessary? So, that is what I do. Very brief therapy to me means that I rarely see clients more than once or twice, with one being the most frequent number of sessions. Of course, I tell each client that I will see them for as many sessions as they feel are helpful.

The essence of what will be the content of this book is how to use expectation in psychotherapy. In a sense, this is akin to the placebo effect, and there is much evidence on how well placebos work in a variety of areas. This chapter introduces a number of related concepts and research. In particular, the work of Wampold, Hubble, Duncan, S. D. Miller and others is discussed in some detail as it directly impacts on the nature of psychotherapy and how it is practiced. In this book I am presenting how I work in the field. Are my methods and my approach significantly better than the hundreds of other approaches out there? Is any one approach better than any other? Why bother reading this book, especially when you are already certain that what you do is the best way to do this work? After all, I am eclectic and pragmatic in how I work—if what I am doing is not working, then I switch to something else. I do have a bunch of preferred things that I do, and I do generally function out of an Ericksonian perspective. These preferred methods are described in the remainder of this book, yet they are presented so that you can read about many different ways of operating effectively and efficiently. What about the research evidence supporting how I work? In effect, I have personally done no research on this subject—as in many books, the evidence is anecdotal, i.e., I really do see my clients only one or two times. Since I do have a background as a “hard” scientist (I have spent most of my adult professional life as a professor of chemistry, and I am still actively functioning in that capacity), it is incumbent upon me to present some research in the field. Therefore, I am going to do that in this chapter by first citing (in the next section) the work of a qualified academic researcher (B. E. Wampold). This is followed by a description of the ongoing research being carried out by B. L. Duncan and S. D. Miller and colleagues. Finally, the seminal work of Talmon on single session therapy is discussed. It is my hope that the remainder of the book proves useful to you.

1.2 The Great Psychotherapy Debate

This is the title of Wampold’s book (2001) summarizing an enormous amount of research on psychotherapy. This book is a solid example of a scholar at work, and it is replete with relevant references—the interested reader is urged to consult them. This section sets the stage for the rest of this book to whet the reader’s appetite. At the outset, Wampold (p. 2) states, “The pressures of the health care delivery system have molded psychotherapy to resemble medical treatments.” Then, he states categorically (p. 2), “In this book, the scientific evidence will be presented that shows that psychotherapy is incompatible with the medical model and that conceptualizing psychotherapy in this way distorts the name of the endeavor.” To start off, he offers the following working definition of psychotherapy (p. 3):

Psychotherapy is a primarily interpersonal treatment that is based on psychological principles and involves a trained therapist and a client who has a mental disorder, problem, or complaint; it is intended by the therapist to be remedial for the client’s disorder, problem, or complaint; and it is adapted or individualized for the particular client and his or her disorder, problem, or complaint.

Wampold contrasts the medical model with the contextual model. They are both summarized here before continuing with describing his results (see pp. 13–20).

1.2.1 Five Components of the Medical Model

1. As the first component of the medical model of psychotherapy, a client is conceptualized to have a disorder, problem, or complaint. DSM-IV (American Psychiatric Association, 1994) is one way of categorizing (mental) disorders, but these diagnoses are not necessary for the application of the medical model to psychotherapy.

2. For the second component, a psychological explanation for the client’s disorder, problem, or complaint is proposed. Since there are many approaches to psychotherapy, there are also many alternative explanations for a given disorder. This is generally not the case for medical disorders.

3. In the medical model of psychotherapy, it is stipulated that each psychotherapeutic approach incorporate a mechanism of change. That is, each theory or approach of psychotherapy implicitly or explicitly involves a mechanism, such as making the unconscious conscious in psychodynamic approaches.

4. There are specific therapeutic actions prescribed, often in treatment manuals. That is, a diagnosis of X requires a treatment of Y.

5. With regard to specificity, which is the critical aspect of the medical model, there is an implication that there are specific therapeutic ingredients which are remedial for a particular disorder, problem or complaint.

The medical model has, of course, worked quite well for medical problems. Yet, impressing that model with its empirically supportedtreatments (ESTs) and its diagnostically related groups (DRGs) into the radically different situation of psychotherapy requires a leap of faith worthy of the most fundamentalist religions.

With respect to the contextual model, Wampold writes (p. 27):

The contextual model states that the treatment procedures used are beneficial to the client because of the meaning attributed to those procedures rather than because of their specific psychological effects. [Emphasis added.]

That is, in this model it is the common contextual factors that are emphasized. Wampold cites Frank and Frank (1991) with respect to the components shared by all approaches to psychotherapy:

1. Psychotherapy involves an emotionally charged, confiding relationship with a helping person (the therapist).

2. There is a healing setting in which the client talks to a helping professional the client believes can help him or her.

3. There exists a rationale, a conceptual scheme, or a myth that provides a plausible explanation for the client’s symptoms, and also provides a ritual or procedure for resolving them. In this wise, the client must believe in the treatment, or be led to believe in it. [RB comment: this involves an element of the placebo effect.]

Wampold then cites (p. 25) six elements discussed by Frank and Frank (1991) as being common to the rituals and procedures used by all psychotherapists:

First, the therapist combats the client’s sense of alienation by developing a relationship that is maintained after the client divulges feelings of demoralization. Second, the therapist maintains the client’s expectation of being helped by linking hope for improvement to the process of therapy. Third, the therapist provides new learning experiences. Fourth, the client’s emotions are aroused as a result of the therapy. Fifth, the therapist enhances the client’s sense of mastery or self-efficacy. Sixth, the therapist provides opportunities for practice.

A basic question that has been studied for decades is: “Does psychotherapy work?” That is, is it effective in helping clients? Grissom (1996) reviewed 68 meta-analyses that had collected results from studies comparing psychotherapies with no-treatment controls. He found an aggregate effect size of 0.75 for the efficacy of psychotherapy. Other similar studies over the years have shown an effect size in the range of 0.75 to 0.85. This means that the average client receiving psychotherapy is better off than about 80% of untreated clients. A reasonable conclusion from these studies is that psychotherapy is remarkably efficacious in helping clients. This result does not support, of course, either the contextual model or the medical model, but it is comforting to know that psychotherapy is useful.

The next question with regard to psychotherapy has to do with relativeefficacy, i.e., are there some approaches that are clearly more