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The scientist-practitioner connection: Myth or reality? A response to Perrez
New I&u tn P,yhol. Vol 7, No. 2. pp. 147-154. I989 printed in Great Brirain
0732-l 10x/89 $3.00 + 0.0 0 1989 Pcrgamon Yress plc
THE SCIENTIST-PRACTITIONER CONNECTION: OR REALITY? A RESPONSE TO PERREZ* FREDERICK Department
of Psychology,
University
MYTH
H. KANFER of Illinois,
Champaign,
IL 61820,
U.S.A.
In his paper on psychotherapeutic methods between scientific foundation and everyday knowledge, Perrez raises important issues of the relationship between psychotherapy practice and the body of knowledge and theories of general psychology. In the present paper, I will limit myself to discussion of some of these issues from the perspective of the similarities and differences of the practicing therapist and the practicing theoretician and researcher. Sociocultural, political and historical factors have shaped a different focus of American and European writers in the discussion of the scientific basis of psychotherapy and in the justification of therapy as an enterprise that has both validity and utility. While European writers have tended to emphasize the structural and formal characteristics of theoretical systems in their relationships to clinical events and actions, American writers have been more concerned with the extent to which psychological theories and empirical (laboratory) knowledge can guide the action of practitioners and define the professional image and identity of psychotherapists. It is from this pragmatic perspective that I view the issues. During the days of the dominance of behaviorism in psychology, there was little question about the underlying philosophy of science. Logical positivism or logical empiricism has been called “the standard view” (Scheffler, 1967). Only recently has there been criticism of the approach that viewed the scientific method as an infallible approach to obtaining data that are neutral with respect to theories and rules of relationships among theoretical terms and the connection between theoretical terms and observations. This standard view of science has come under attack from numerous quarters. Particularly relevant to the field of psychotherapy has been the development of alternate views concerning the rules for obtaining empirical knowledge, the role of ethics and values in the scientific or applied enterprise and the influence of the observer, whether scientist or practitioner, on selective attention to and distortion of presumably objective data. Clinical psychology in the United States has been heavily influenced by the various training models for psychologists. The dominant model for three decades has been the scientist-practitioner model, first proposed in the Conference on Training at the Boulder Conference in 1949. It sketched a world in which clinical practitioners trained in the methods and body of knowledge of general psychology would simply apply the concepts and discoveries of psychological science to solve
* A commentary on M. Perrez (1989) Psychotherapeutic methods between scientific foundation and everyday knowledge, Vol. 7, No. 2, pp. 133-145. Ackuowldgemenl- I wish to thank H. Reinecker for his critical reading of the manuscript. 147
148
Frederick H. Kanfer
the problems encountered in their daily practice. This view made psychotherapy appear respectable. More recently, the utility of the traditional‘ methods of natural sciences for psychotherapy has been challenged on various grounds (Koch, 198 1; Frank, 1987). In fact, Frank suggests that the main power of any scientific approach to psychotherapy is derived less from its contents and method than from the strong position that any enterprise labeled Science has in the American culture. The Boulder training model has not been fully successful in creating the person who can conduct therapy completely on a scientific basis. Clearly, what is lacking are rules for telling clinicians when to do what, to which patient and for what purpose. For these rules, current scientific knowledge is insufficient. In fact, as Kaminski (1970) has suggested in his analysis of clinical, activities, a rich fund of information, derived from the professional literature (the “folk lore of psychotherapists”) and from personal experience, as well as from science, enables the client to make many decisions, including those about the timing and selection of scientific principles to guide therapeutic procedures for individual clients and situations. Psychotherapy is a problem-solving endeavor in which a professional assists a client in altering ineffective or pathological ways of thinking, behaving or reacting emotionally. Does such an enterprise need to be scientific? Is it sufficient if the clinician’s activities are rooted in part in scientific knowledge and in part in pragmatic considerations ? If we can distinguish theoretical, technological and action levels of knowledge, like Perrez (cf. Reinecker, 1987), at which level should a conceptual framework for psychotherapy be founded? DIFFERENCES
BETWEEN
PRACTITIONER
AND SCIENTIST
To provide a better perspective for a resolution of these questions, it is useful to describe eight areas in which the activities of the scientist and practitioner differ. An analysis of these differences should make it clear that conceptual scientific systems and systems of psychotherapy practice cannot be identical. What can be done is to shift from one arena to the other. Theories from general psychology and data from controlled laboratory observations can serve as heuristics for particular strategies and operations in psychotherapy, if the clinical situation meets the requirement of similarity to the specified situations under which the scientifically established relationship has been observed to hold. In turn, clinical experience and observations can suggest consistencies that point to relationships among variables for psychological processes to be studied further in the laboratory. In essence, the proper relationship between theory and practice moves both in the top-down and bottom-up directions in which an inductive approach by collecting experiences in the clinic represents the latter and the investigation concerning the robustness of the laboratory derived scientific findings in the clinical situation represents the former. Sources of data inputs. In contrast to the laboratory situation in which the experimenter pre-selects the range of possible events to be observed and limits the different types of responses that the subjects can make, the clinician is bombarded with information in all modalities. Without the filtering of information that occurs in the laboratory, the relevance of various components of the total information input needs to be determined on the spot by the
The scientist-practitioner
connection
149
clinician. Although a psychotherapist may make some a priori decisions about what he or she will attend to or disregard, unexpected information may seduce the clinician to shift attention. Further, in contrast to the laboratory researcher, the therapist responds not only to external sources of information, but also to self-generated and internal inputs. Therapists attend and react to their own reactions, as well as to the behavior of their clients. Purpose andfocus. The scientist starts with a testable hypothesis. The constructs are anchored by operationalization and, a clear statement of measures to be taken. The specific purpose of the scientist’s endeavor is not constrained, in principle, by an expected and desired outcome. Given the context in which an experiment is designed and scientific data are obtained, the scientist can predict in advance what implications a particular outcome will have for support or refutation of a hypothesis. Data collection follows hypothesis generation; post hoc hypotheses are occasional by-products of research, but the inductive and deductive phases are usually clearly separated. The contexts of discovery and of justification (Reichenbach, 1938) describe the scientist’s different approaches to the use of personal experiences and controlled experimental data. In clinical the contexts tend to blend. Observations precede hypothesissituations, formation, although tests are then set up to verify the reliability and validity of these observations. Further, the purpose of a therapeutic enterprise is dictated to the clinician by the nature of the client’s problem, the context and practical constraints on both client and therapist. Indeed, the development of a goal and purpose of the enterprise is in itself part of the therapy process. In addition, the very change that is brought about in therapy frequently results in successive reevaluations and alterations of the purpose of therapy and its goals. Success criztetia. Fairly well-established criteria are used for evaluating the outcome of an experiment. Use of statistical methods guards against biases and chance occurrences that may distort the conclusions reached. The concurrence with predicted outcomes and, at times, the generation of new hypotheses as well as the fit of results with an underlying theory yield criteria for the success of an experiment. The validity and reliability of the findings represent the primary criteria on which the success of an experiment is assessed. In a clinical situation, criteria have varied. In behavioral approaches they have been the change in a client’s emotional reactions, attitude, or behaviors. In other schools, insight or causal explanations or increased client tolerance of their distress have been used as criteria. But in all schools utility of the therapy process, consistent with its goals and theories, is the main criterion. When only utility or outcome is the focus of attention, there is little opportunity for improvement, since the entire complex of the underlying theoretical framework, case formulation, and implementation of procedures remains unanalyzed. Further, utility is often not only a function of the clinician’s activities but also of the social context and its reaction to the client’s change. As a result, utility may change during the course of therapy. It further needs to be continually defined with respect to both goals and subgoals in the therapeutic enterprise. Although utility is the ultimate criterion, it must be applied to processes and components, rather than to the whole “therapy-package.”
150
Frederick H. Kanfer
Language. A characteristic of scientific communication is the clear and unequivocal definition of terms so that an object, phenomenon or event can be clearly identified or even replicated, regardless of the person’s theoretical persuasion or personal characteristics. Scientific theories coin terms unique to their own domain or unique even to a theory within a specific domain. Nevertheless, the meaning of terms and their objective referent is shared by all workers in the area. Further, in most experimental work, technical terms are used to avoid misinterpretation or surplus meaning often found in popular terminology. Clinicians tend to describe events at a data level which uses every day popular language. Client input of events, given by clients in their own common language, are often equated with description of psychological processes, relationships or terms that have been used at the level of psychological constructs or theories. Careful transformation of the client’s report or actions into the technical language or theoretical terms is frequently attempted, to make statements that can be used as data. But these translations involve personal judgements and biases of the clinician since no general rules have been developed for such transformations. Size of data units. The laboratory permits the deliberate isolation of a specific event and its determinants into small components so that a micro-analysis of psychological processes can be undertaken. In fact, observation of a specific response during a short period of time is used to reduce contamination by noise and fluctuations in the person’s activity that are extraneous to the experimental target. In contrast, the clinician deals with macro-units of behavior. Analysis of interpersonal relationships, family systems or symptoms of pathology include behavioral patterns that extend over a wide domain, over different situations that utilize strict and an extended period of time. Except for techniques chunking of laboratory analogs, such as classical’ or operant conditioning, responses is a rule rather than the exception in the clinic. Subject matter. Scientific research is guided by some conceptual framework or theory that attempts to examine phenomena that are bounded in their extent and time. The subject matter of an experiment may be an emotional process, a memory process, a social interactional process, etc. In each case, the domain is limited by the mini-theory that covers some small portion of human behavior and the specificity of the experimenter’s hypothesis. By contrast, psychotherapy deals with not only the richness, diversity and complexity of the individual, but also with subject matters that range from conflicts with sociocultural environments, intra-personal conflicts, emotional reactions to responses to biological changes or illness, among myriads of other areas. Clearly, what may be central in an experiment, may be only a tiny component in the total pattern presented to the clinician. Some psychotherapeutic theories present a single, central mechanism to account for the changes during the psychotherapeutic process. Even in such theories, for example, those based on the conditioning paradigm, the interplay between conflicting intra- and interpersonal variables, the irrationality of a client’s thinking or the disturbance in a person’s self-system, or the relationship-context (with the therapist or others), all of these by necessity transcend the domain in which the simple model of psychopathology and
The scientist-practitioner
connection
151
therapy has been developed and substantiated by research. Ethics. During the process of experimenting or during theory construction, the paramount ethical concern is the faithful report of the scientist of his or her operations. Obviously, ethical principles extend to the societal rules for dealing with live subjects and to concern that no harm be done by the experiment. In the application of science to everyday life a different set of ethical problems arises (Hutchinson, 1983). In application long-term benefits or harm must be weighed against the expenditure of effort and other resources in the therapeutic enterprise. Within the scientific community there recently have been wide discussions concerning the mission of science. For example, justification of the scientific enterprise is found by some to lie in the legitimate curiosity about the nature of our universe, while others believe that scientific work is justifiable only because of its potential contributions to society. As Perrez points out, a therapeutic enterprise requires justification for use of a method in terms of expected outcome, acceptability of the method itself, possible side effects and cost. Legitimatization of a therapeutic procedure is often based not on its immediate effect but on a comparison to what is given up, either in the use of other approaches or in treatment of other persons, when a commitment is made to the specific procedure. While basic research may ultimately have some utility in everyday life, justification for clinical methods is demanded even as their application is contemplated. Static us. dynamic nature. Basic psychology has often been faulted for its disregard of one of the most important critical variables that affect humanitytime. While most basic psychological models are relatively static, psychotherapy frameworks extend along historical dimensions, over long periods of time. The dynamic aspect further involves the continuous change in interrelationships among components of the system that make up the individual and his environment. In contrast to the laboratory setting, the everyday world is not fixed. Historical accident, predispositions, cultural changes and just the mere passage of time affect the therapeutic process. Therapeutic change begets further change. While psychological theories study component phenomena, researchers on the psychotherapy process study human beings in an everchanging context. As a result, static models, linear predictions and crosssectional analyses of processes and relationships are insufficient for study and use in psychotherapy (Kanfer & Busemeyer, 1982). IMPLICATIONS
FOR TRAINING
The direction of a discipline is strongly influenced by the formal curricula that prepare scientists and practitioners. American universities and professional schools utilize two different approaches. For some the preparation for clinical practice has followed the assumption that a thorough knowledge of the basic scientific principles of psychology is central in preparing a person to apply them in practice. This declarative knowledge represents a stock pile of information about relationships between psychological events and their settings, their correlates and their antecedents. A second ingredient of training is represented by a knowledge of the technology needed to assess and influence human
152
Frederick
H. Kanfer
behavior. This technology includes a series of guidelines for action to achieve specified outcomes within the limits of the existing conditions and implements; and it includes some heuristics for recognizing special patient characteristics such as different psychopathologies, or special conditions such as pathological family constellations, that influence the utility of a given technique. Finally, training settings that emphasize the professional aspect of psychologists devote much attention to assessing and shaping the personal qualifications and skills of the therapists. Among these is an awareness of the personal biases and limitations that distort the perception of the client and the preference for certain techniques and outcomes, as well as the skills needed to know when, to whom and how to apply existing knowledge and techniques. The extremes of these approaches are represented by the meta-theoretical assumptions of psychoanalysis and radical behaviorism that flourished as antagonists for several decades. The former represented the heavy emphasis on the personal qualifications of the therapists while the latter viewed therapists as nearly interchangeable, as implements in the execution of a research derived technique. Current trends stress the continuous interplay between these three ingredients and therefore the need for including declarative knowledge of psychological principles, of available technology and the development of personal qualifications and skills in the preparation of psychotherapists. BRINi;ING
PSYCHOLOGICAL SCIENCE AND CLINICAL CLOSER TOGETHER
PRACTICE
A possible sequence of steps can be outlined that may assure that available scientific knowledge is effectively utilized in clinical practice. The clinician must begin with a clinical phenomenon and then take several steps to tap research and theories that may help in the formulation of the clinical problem. Subsequently, an excursion in the opposite direction is necessary. That is, having formulated the problem, the translation must be made again into appropriate strategies and techniques with a clinical case. This approach can be summarized in seven steps: (1) Formulate the clinical problem in the language of science. (2) Scan the field for principles and research findings relevant to the restated problem. (3) Examine the relevance of other variables or adjacent science-based data domains, such as those related to the social context, to biological variables or to sociopolitical influences. (4) Describe, at the theoretical level the desired outcomes and the psychological processes that need to be influenced. Formulate intervention strategies based on these considerations. (5) Search technology and define specific case related parameters that may limit or enhance the feasibility and practicality of the methods. (6) Apply the method. Monitor its effects and compare them against outcome criteria. (7) If desired effects are not obtained, recurse either to 1, or 4 or 5, as needed. The other interaction that is needed to strengthen the bond between the fields of theory, research and application is one in which the clinician offers
The scientist-practitioner
connection
153
hypotheses and questions to the scientist. Repeated behavioral patterns or events, even though noted at first by subjective observation, can eventually yield a series of research questions. They must then be put into testable form in order to stimulate research within the framework of a particular scientific subdomain. In this way, clinicians can contribute as well to an expansion of scientific knowledge by calling attention to phenomena that appear with some regularity in the natural everyday setting. This stimulating function of clinical psychologists has been badly neglected except for persons who are actively engaged both in scientific research and clinical practice. Simplicity and logical consistency are the hallmarks of scientific research. I believe that all humans share a craving for simple and unitary explanation and It is more exciting to build grand theories from which natural phenomena. simple explanations can be derived to cover all phenomena than to go about the tedious job of filling gaps in theoretical framework by providing the minute details that may yield eventual guidelines for day-to-day clinical operations. Unfortunately, simplicity is not a characteristic of human behavior. It would be nice to fmd a single mechanism, be it conditioning, a neural mechanism or a libido principle, to account for pathology and its remediation. However, the continuing ebb and flow and the recursiveness of human actions, both at various intra- and interpersonal levels requires clinical skills for evaluating those factors in a situation that have the most weight, can be most easily modified and are likely to yield the most desired outcome for a problem with which clients confront a clinician. Clearly, such goals would be unacceptable to the scientist. There are many similarities between the reasoning processes of scientists and clinicians. However, in addition, clinicians must be trained to behave in ways that enact these ideas. Thus, although both groups may think similarly, their actions are quite different. The task of relating scientific principles to practical interventions and of stimulating scientific research by use of the experience gained by clinicians would be made easier if some psychologists would focus on each of two separate tasks. First, there is the task of recognizing and testing the utility of various minitheories for clinical operations. This activity already is carried out by some psychologists, but it would be well if they would also devote some energy to developing heuristics for the translation of new research findings into practical operations. Secondly, a rapprochement between the two areas would be facilitated. if greater attention were devoted to observation of consistently occurring clinical phenomena and, in discussion with research-oriented clinicians, were translated into scientific language in order to formulate research questions about these phenomena. At the present time clinical psychologists have tended to work in the opposite direction, starting with a theory of personality or psychopathology and then searching for data to fit or confirm their hypothesis. While our approach may be limited by weaknesses and biases in human information processing (Turk 8c Salovey, 1988), they can be overcome with concerted effort. But building better bridges between scientific knowledge and practical application, to be transversed in both directions, will surely benefit both areas.
154
Frederick
H. Kanfer
REFERENCES Frank, J. D. (1987). Psychotherapy, rhetoric, and hermeneutics: Implications for practice and research. Psychotherapy, 24, 293-302. Hutchinson, G. E. (1983). What is science for? American Scientist, 71, 639-644. Kaminski, G. (1970). Verhaltenstheorie und Verhaltensmodz~ikation. Stuttgart: Ernst Klett. Kanfer, F. H., & Busemeyer, J. P. (1982). The use of problem-solving and decisionmaking in behavior therapy. Clinical Psychology Review, 2, 239-266. Koch, S. (1981). The nature and limits of psychological knowledge. American Psychologist, 36, 257-269.
Reichenbach, H. (1938). Experience and prediction. Chicago: University of Chicago Press. Reinecker, H. (1987). Grundlagen der Verhaltenstherapie. Munich: Psychologie-VerlagsUnion. Scheffler, 1. (1967). Science and subjectivity. New York: Bobbg-Merrill. Turk, D. C., & Salovey, P. (Eds.) (1988). Reasoning, inference and judgment in clinical psychology. New York: The Free Press.
0732-l 10x/89 $3.00 + 0.0 0 1989 Pcrgamon Yress plc
THE SCIENTIST-PRACTITIONER CONNECTION: OR REALITY? A RESPONSE TO PERREZ* FREDERICK Department
of Psychology,
University
MYTH
H. KANFER of Illinois,
Champaign,
IL 61820,
U.S.A.
In his paper on psychotherapeutic methods between scientific foundation and everyday knowledge, Perrez raises important issues of the relationship between psychotherapy practice and the body of knowledge and theories of general psychology. In the present paper, I will limit myself to discussion of some of these issues from the perspective of the similarities and differences of the practicing therapist and the practicing theoretician and researcher. Sociocultural, political and historical factors have shaped a different focus of American and European writers in the discussion of the scientific basis of psychotherapy and in the justification of therapy as an enterprise that has both validity and utility. While European writers have tended to emphasize the structural and formal characteristics of theoretical systems in their relationships to clinical events and actions, American writers have been more concerned with the extent to which psychological theories and empirical (laboratory) knowledge can guide the action of practitioners and define the professional image and identity of psychotherapists. It is from this pragmatic perspective that I view the issues. During the days of the dominance of behaviorism in psychology, there was little question about the underlying philosophy of science. Logical positivism or logical empiricism has been called “the standard view” (Scheffler, 1967). Only recently has there been criticism of the approach that viewed the scientific method as an infallible approach to obtaining data that are neutral with respect to theories and rules of relationships among theoretical terms and the connection between theoretical terms and observations. This standard view of science has come under attack from numerous quarters. Particularly relevant to the field of psychotherapy has been the development of alternate views concerning the rules for obtaining empirical knowledge, the role of ethics and values in the scientific or applied enterprise and the influence of the observer, whether scientist or practitioner, on selective attention to and distortion of presumably objective data. Clinical psychology in the United States has been heavily influenced by the various training models for psychologists. The dominant model for three decades has been the scientist-practitioner model, first proposed in the Conference on Training at the Boulder Conference in 1949. It sketched a world in which clinical practitioners trained in the methods and body of knowledge of general psychology would simply apply the concepts and discoveries of psychological science to solve
* A commentary on M. Perrez (1989) Psychotherapeutic methods between scientific foundation and everyday knowledge, Vol. 7, No. 2, pp. 133-145. Ackuowldgemenl- I wish to thank H. Reinecker for his critical reading of the manuscript. 147
148
Frederick H. Kanfer
the problems encountered in their daily practice. This view made psychotherapy appear respectable. More recently, the utility of the traditional‘ methods of natural sciences for psychotherapy has been challenged on various grounds (Koch, 198 1; Frank, 1987). In fact, Frank suggests that the main power of any scientific approach to psychotherapy is derived less from its contents and method than from the strong position that any enterprise labeled Science has in the American culture. The Boulder training model has not been fully successful in creating the person who can conduct therapy completely on a scientific basis. Clearly, what is lacking are rules for telling clinicians when to do what, to which patient and for what purpose. For these rules, current scientific knowledge is insufficient. In fact, as Kaminski (1970) has suggested in his analysis of clinical, activities, a rich fund of information, derived from the professional literature (the “folk lore of psychotherapists”) and from personal experience, as well as from science, enables the client to make many decisions, including those about the timing and selection of scientific principles to guide therapeutic procedures for individual clients and situations. Psychotherapy is a problem-solving endeavor in which a professional assists a client in altering ineffective or pathological ways of thinking, behaving or reacting emotionally. Does such an enterprise need to be scientific? Is it sufficient if the clinician’s activities are rooted in part in scientific knowledge and in part in pragmatic considerations ? If we can distinguish theoretical, technological and action levels of knowledge, like Perrez (cf. Reinecker, 1987), at which level should a conceptual framework for psychotherapy be founded? DIFFERENCES
BETWEEN
PRACTITIONER
AND SCIENTIST
To provide a better perspective for a resolution of these questions, it is useful to describe eight areas in which the activities of the scientist and practitioner differ. An analysis of these differences should make it clear that conceptual scientific systems and systems of psychotherapy practice cannot be identical. What can be done is to shift from one arena to the other. Theories from general psychology and data from controlled laboratory observations can serve as heuristics for particular strategies and operations in psychotherapy, if the clinical situation meets the requirement of similarity to the specified situations under which the scientifically established relationship has been observed to hold. In turn, clinical experience and observations can suggest consistencies that point to relationships among variables for psychological processes to be studied further in the laboratory. In essence, the proper relationship between theory and practice moves both in the top-down and bottom-up directions in which an inductive approach by collecting experiences in the clinic represents the latter and the investigation concerning the robustness of the laboratory derived scientific findings in the clinical situation represents the former. Sources of data inputs. In contrast to the laboratory situation in which the experimenter pre-selects the range of possible events to be observed and limits the different types of responses that the subjects can make, the clinician is bombarded with information in all modalities. Without the filtering of information that occurs in the laboratory, the relevance of various components of the total information input needs to be determined on the spot by the
The scientist-practitioner
connection
149
clinician. Although a psychotherapist may make some a priori decisions about what he or she will attend to or disregard, unexpected information may seduce the clinician to shift attention. Further, in contrast to the laboratory researcher, the therapist responds not only to external sources of information, but also to self-generated and internal inputs. Therapists attend and react to their own reactions, as well as to the behavior of their clients. Purpose andfocus. The scientist starts with a testable hypothesis. The constructs are anchored by operationalization and, a clear statement of measures to be taken. The specific purpose of the scientist’s endeavor is not constrained, in principle, by an expected and desired outcome. Given the context in which an experiment is designed and scientific data are obtained, the scientist can predict in advance what implications a particular outcome will have for support or refutation of a hypothesis. Data collection follows hypothesis generation; post hoc hypotheses are occasional by-products of research, but the inductive and deductive phases are usually clearly separated. The contexts of discovery and of justification (Reichenbach, 1938) describe the scientist’s different approaches to the use of personal experiences and controlled experimental data. In clinical the contexts tend to blend. Observations precede hypothesissituations, formation, although tests are then set up to verify the reliability and validity of these observations. Further, the purpose of a therapeutic enterprise is dictated to the clinician by the nature of the client’s problem, the context and practical constraints on both client and therapist. Indeed, the development of a goal and purpose of the enterprise is in itself part of the therapy process. In addition, the very change that is brought about in therapy frequently results in successive reevaluations and alterations of the purpose of therapy and its goals. Success criztetia. Fairly well-established criteria are used for evaluating the outcome of an experiment. Use of statistical methods guards against biases and chance occurrences that may distort the conclusions reached. The concurrence with predicted outcomes and, at times, the generation of new hypotheses as well as the fit of results with an underlying theory yield criteria for the success of an experiment. The validity and reliability of the findings represent the primary criteria on which the success of an experiment is assessed. In a clinical situation, criteria have varied. In behavioral approaches they have been the change in a client’s emotional reactions, attitude, or behaviors. In other schools, insight or causal explanations or increased client tolerance of their distress have been used as criteria. But in all schools utility of the therapy process, consistent with its goals and theories, is the main criterion. When only utility or outcome is the focus of attention, there is little opportunity for improvement, since the entire complex of the underlying theoretical framework, case formulation, and implementation of procedures remains unanalyzed. Further, utility is often not only a function of the clinician’s activities but also of the social context and its reaction to the client’s change. As a result, utility may change during the course of therapy. It further needs to be continually defined with respect to both goals and subgoals in the therapeutic enterprise. Although utility is the ultimate criterion, it must be applied to processes and components, rather than to the whole “therapy-package.”
150
Frederick H. Kanfer
Language. A characteristic of scientific communication is the clear and unequivocal definition of terms so that an object, phenomenon or event can be clearly identified or even replicated, regardless of the person’s theoretical persuasion or personal characteristics. Scientific theories coin terms unique to their own domain or unique even to a theory within a specific domain. Nevertheless, the meaning of terms and their objective referent is shared by all workers in the area. Further, in most experimental work, technical terms are used to avoid misinterpretation or surplus meaning often found in popular terminology. Clinicians tend to describe events at a data level which uses every day popular language. Client input of events, given by clients in their own common language, are often equated with description of psychological processes, relationships or terms that have been used at the level of psychological constructs or theories. Careful transformation of the client’s report or actions into the technical language or theoretical terms is frequently attempted, to make statements that can be used as data. But these translations involve personal judgements and biases of the clinician since no general rules have been developed for such transformations. Size of data units. The laboratory permits the deliberate isolation of a specific event and its determinants into small components so that a micro-analysis of psychological processes can be undertaken. In fact, observation of a specific response during a short period of time is used to reduce contamination by noise and fluctuations in the person’s activity that are extraneous to the experimental target. In contrast, the clinician deals with macro-units of behavior. Analysis of interpersonal relationships, family systems or symptoms of pathology include behavioral patterns that extend over a wide domain, over different situations that utilize strict and an extended period of time. Except for techniques chunking of laboratory analogs, such as classical’ or operant conditioning, responses is a rule rather than the exception in the clinic. Subject matter. Scientific research is guided by some conceptual framework or theory that attempts to examine phenomena that are bounded in their extent and time. The subject matter of an experiment may be an emotional process, a memory process, a social interactional process, etc. In each case, the domain is limited by the mini-theory that covers some small portion of human behavior and the specificity of the experimenter’s hypothesis. By contrast, psychotherapy deals with not only the richness, diversity and complexity of the individual, but also with subject matters that range from conflicts with sociocultural environments, intra-personal conflicts, emotional reactions to responses to biological changes or illness, among myriads of other areas. Clearly, what may be central in an experiment, may be only a tiny component in the total pattern presented to the clinician. Some psychotherapeutic theories present a single, central mechanism to account for the changes during the psychotherapeutic process. Even in such theories, for example, those based on the conditioning paradigm, the interplay between conflicting intra- and interpersonal variables, the irrationality of a client’s thinking or the disturbance in a person’s self-system, or the relationship-context (with the therapist or others), all of these by necessity transcend the domain in which the simple model of psychopathology and
The scientist-practitioner
connection
151
therapy has been developed and substantiated by research. Ethics. During the process of experimenting or during theory construction, the paramount ethical concern is the faithful report of the scientist of his or her operations. Obviously, ethical principles extend to the societal rules for dealing with live subjects and to concern that no harm be done by the experiment. In the application of science to everyday life a different set of ethical problems arises (Hutchinson, 1983). In application long-term benefits or harm must be weighed against the expenditure of effort and other resources in the therapeutic enterprise. Within the scientific community there recently have been wide discussions concerning the mission of science. For example, justification of the scientific enterprise is found by some to lie in the legitimate curiosity about the nature of our universe, while others believe that scientific work is justifiable only because of its potential contributions to society. As Perrez points out, a therapeutic enterprise requires justification for use of a method in terms of expected outcome, acceptability of the method itself, possible side effects and cost. Legitimatization of a therapeutic procedure is often based not on its immediate effect but on a comparison to what is given up, either in the use of other approaches or in treatment of other persons, when a commitment is made to the specific procedure. While basic research may ultimately have some utility in everyday life, justification for clinical methods is demanded even as their application is contemplated. Static us. dynamic nature. Basic psychology has often been faulted for its disregard of one of the most important critical variables that affect humanitytime. While most basic psychological models are relatively static, psychotherapy frameworks extend along historical dimensions, over long periods of time. The dynamic aspect further involves the continuous change in interrelationships among components of the system that make up the individual and his environment. In contrast to the laboratory setting, the everyday world is not fixed. Historical accident, predispositions, cultural changes and just the mere passage of time affect the therapeutic process. Therapeutic change begets further change. While psychological theories study component phenomena, researchers on the psychotherapy process study human beings in an everchanging context. As a result, static models, linear predictions and crosssectional analyses of processes and relationships are insufficient for study and use in psychotherapy (Kanfer & Busemeyer, 1982). IMPLICATIONS
FOR TRAINING
The direction of a discipline is strongly influenced by the formal curricula that prepare scientists and practitioners. American universities and professional schools utilize two different approaches. For some the preparation for clinical practice has followed the assumption that a thorough knowledge of the basic scientific principles of psychology is central in preparing a person to apply them in practice. This declarative knowledge represents a stock pile of information about relationships between psychological events and their settings, their correlates and their antecedents. A second ingredient of training is represented by a knowledge of the technology needed to assess and influence human
152
Frederick
H. Kanfer
behavior. This technology includes a series of guidelines for action to achieve specified outcomes within the limits of the existing conditions and implements; and it includes some heuristics for recognizing special patient characteristics such as different psychopathologies, or special conditions such as pathological family constellations, that influence the utility of a given technique. Finally, training settings that emphasize the professional aspect of psychologists devote much attention to assessing and shaping the personal qualifications and skills of the therapists. Among these is an awareness of the personal biases and limitations that distort the perception of the client and the preference for certain techniques and outcomes, as well as the skills needed to know when, to whom and how to apply existing knowledge and techniques. The extremes of these approaches are represented by the meta-theoretical assumptions of psychoanalysis and radical behaviorism that flourished as antagonists for several decades. The former represented the heavy emphasis on the personal qualifications of the therapists while the latter viewed therapists as nearly interchangeable, as implements in the execution of a research derived technique. Current trends stress the continuous interplay between these three ingredients and therefore the need for including declarative knowledge of psychological principles, of available technology and the development of personal qualifications and skills in the preparation of psychotherapists. BRINi;ING
PSYCHOLOGICAL SCIENCE AND CLINICAL CLOSER TOGETHER
PRACTICE
A possible sequence of steps can be outlined that may assure that available scientific knowledge is effectively utilized in clinical practice. The clinician must begin with a clinical phenomenon and then take several steps to tap research and theories that may help in the formulation of the clinical problem. Subsequently, an excursion in the opposite direction is necessary. That is, having formulated the problem, the translation must be made again into appropriate strategies and techniques with a clinical case. This approach can be summarized in seven steps: (1) Formulate the clinical problem in the language of science. (2) Scan the field for principles and research findings relevant to the restated problem. (3) Examine the relevance of other variables or adjacent science-based data domains, such as those related to the social context, to biological variables or to sociopolitical influences. (4) Describe, at the theoretical level the desired outcomes and the psychological processes that need to be influenced. Formulate intervention strategies based on these considerations. (5) Search technology and define specific case related parameters that may limit or enhance the feasibility and practicality of the methods. (6) Apply the method. Monitor its effects and compare them against outcome criteria. (7) If desired effects are not obtained, recurse either to 1, or 4 or 5, as needed. The other interaction that is needed to strengthen the bond between the fields of theory, research and application is one in which the clinician offers
The scientist-practitioner
connection
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hypotheses and questions to the scientist. Repeated behavioral patterns or events, even though noted at first by subjective observation, can eventually yield a series of research questions. They must then be put into testable form in order to stimulate research within the framework of a particular scientific subdomain. In this way, clinicians can contribute as well to an expansion of scientific knowledge by calling attention to phenomena that appear with some regularity in the natural everyday setting. This stimulating function of clinical psychologists has been badly neglected except for persons who are actively engaged both in scientific research and clinical practice. Simplicity and logical consistency are the hallmarks of scientific research. I believe that all humans share a craving for simple and unitary explanation and It is more exciting to build grand theories from which natural phenomena. simple explanations can be derived to cover all phenomena than to go about the tedious job of filling gaps in theoretical framework by providing the minute details that may yield eventual guidelines for day-to-day clinical operations. Unfortunately, simplicity is not a characteristic of human behavior. It would be nice to fmd a single mechanism, be it conditioning, a neural mechanism or a libido principle, to account for pathology and its remediation. However, the continuing ebb and flow and the recursiveness of human actions, both at various intra- and interpersonal levels requires clinical skills for evaluating those factors in a situation that have the most weight, can be most easily modified and are likely to yield the most desired outcome for a problem with which clients confront a clinician. Clearly, such goals would be unacceptable to the scientist. There are many similarities between the reasoning processes of scientists and clinicians. However, in addition, clinicians must be trained to behave in ways that enact these ideas. Thus, although both groups may think similarly, their actions are quite different. The task of relating scientific principles to practical interventions and of stimulating scientific research by use of the experience gained by clinicians would be made easier if some psychologists would focus on each of two separate tasks. First, there is the task of recognizing and testing the utility of various minitheories for clinical operations. This activity already is carried out by some psychologists, but it would be well if they would also devote some energy to developing heuristics for the translation of new research findings into practical operations. Secondly, a rapprochement between the two areas would be facilitated. if greater attention were devoted to observation of consistently occurring clinical phenomena and, in discussion with research-oriented clinicians, were translated into scientific language in order to formulate research questions about these phenomena. At the present time clinical psychologists have tended to work in the opposite direction, starting with a theory of personality or psychopathology and then searching for data to fit or confirm their hypothesis. While our approach may be limited by weaknesses and biases in human information processing (Turk 8c Salovey, 1988), they can be overcome with concerted effort. But building better bridges between scientific knowledge and practical application, to be transversed in both directions, will surely benefit both areas.
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REFERENCES Frank, J. D. (1987). Psychotherapy, rhetoric, and hermeneutics: Implications for practice and research. Psychotherapy, 24, 293-302. Hutchinson, G. E. (1983). What is science for? American Scientist, 71, 639-644. Kaminski, G. (1970). Verhaltenstheorie und Verhaltensmodz~ikation. Stuttgart: Ernst Klett. Kanfer, F. H., & Busemeyer, J. P. (1982). The use of problem-solving and decisionmaking in behavior therapy. Clinical Psychology Review, 2, 239-266. Koch, S. (1981). The nature and limits of psychological knowledge. American Psychologist, 36, 257-269.
Reichenbach, H. (1938). Experience and prediction. Chicago: University of Chicago Press. Reinecker, H. (1987). Grundlagen der Verhaltenstherapie. Munich: Psychologie-VerlagsUnion. Scheffler, 1. (1967). Science and subjectivity. New York: Bobbg-Merrill. Turk, D. C., & Salovey, P. (Eds.) (1988). Reasoning, inference and judgment in clinical psychology. New York: The Free Press.