A new zone of effectiveness for psychotherapy
By Bruce Ecker and Laurel Hulley
The proliferation of new paradigms of psychotherapy throughout the 20th century has given clinicians radically different ways to understand how patterns of thought, mood and behavior can change. And yet, researchers measure essentially the same modest level of therapeutic effectiveness across the entire spectrum of methodologies - a curious ceiling known as the "Dodo bird verdict" after the creature who declared "all win and all must have prizes" (Seligman, 1995; Wampold, Mondlin, Moody, Stich, Benson, & Ahn, 1997).
Why has a true breakthrough in effectiveness not occurred? We believe that, as different as the various psychotherapy systems are, the ceiling on their effectiveness is the characteristic sign of some shared, root assumptions reaching their limits of usefulness. If this is true, therapies that enter a new, higher zone of effectiveness will do so from a base of new assumptions.
This breakthrough may already be occurring. During the 1990's a cluster of psychotherapeutic methodologies emerged that have demonstrated degrees of accuracy and effectiveness not considered possible within the old assumptions. The table below contrasts the coherence paradigm of these new approaches with the disorder paradigm shaping most 20th-century psychotherapy.
In addition to the modality we developed, depth-oriented brief therapy or DOBT (Ecker & Hulley, 1996, 1998a-b, 2000a-b), the therapies that embody the new coherence movement include family themes (Papp & Imber-Black, 1996), dialectical constructivism (Greenberg & Pascual-Leone, 1995), eye movement desensitisation and reprocessing or EMDR (Shapiro, 1995), and traumatic incident reduction or TIR (French & Harris, 1998). Several other modalities can cross over into the new zone if suitably adapted by a clinician working from a stance in the coherence paradigm: focusing (Gendlin, 1978, 1996), internal family systems (Schwartz, 1995), Gestalt therapy (Perls, 1973), neuro-linguistic programming or NLP (Bandler & Grinder, 1982), and narrative therapy (White & Epston, 1990).
These approaches are neither panaceas nor miracle cures, but with skillful application can often achieve genuine in-depth resolution of longstanding symptoms in a small number of sessions - a level of effectiveness not considered possible within the old assumptive framework. This assertion summarises the clinical findings of many therapists, including ourselves, working within the model of the local clinical scientist, in which the therapy hour is viewed as analogous to a scientific laboratory (Stricker & Trierweiler, 1995).
Assumptions old and new
Nearly all 20th-century psychotherapies regard clinical symptoms as disorders, whether construed as illness, dysfunction, or maladaptation. We believe methods based in this view inherently maintain the low ceiling on effectiveness. In contrast, the coherence paradigm's constructivist understanding of symptom production can position the therapist to carry out in-depth work with extraordinary dexterity and accuracy.
In the constructivist view, the mind of each person functions with complete coherence according to the constructions of reality currently applied for organizing experience and seeking survival and wellness (Ecker & Hulley, 1996, 2000a-b; Guidano, 1995; Mahoney, 1995; Neimeyer, 1997). When clinical symptoms such as depression, anxiety, obsessing, dissociation, etc. are understood in the context of the specific formations of reality actually giving rise to them, these symptoms are revealed to be no less cogent as responses to circumstances than any supposedly healthy thoughts, feelings or behaviors that people produce. The constructivist therapist's task is to prompt the mind's use of its potent capacity to revise its own renditions or schemas of reality that are maintaining symptoms. This is neither a "cure" nor a manipulation applied by the therapist but a natural change made by the client in his or her evolving construction of self and world.
Which particular reality-defining formation is the one responsible for the symptom? Here we encounter the meaning of symptom coherence: In the construction maintaining symptom production, the symptom is in some way compellingly necessary to have. The various therapies utilizing this coherence zero in on the same target material in different ways (though only DOBT's methodology is completely and explicitly organized around the coherence principle).
How does the client actually access and dissolve an unconscious schema coherently requiring the symptom? Surprisingly, not by counteracting, overcoming, circumventing, or disconnecting from it at all, as virtually all 20th-century therapies aim to do. Rather, the client connects with the governing reality-schema by directly experiencing the emotional reality it engenders. Only such subjective accessing makes the material available for immediate dissolution. The experiential nature of the process is a crucial ingredient for heightened effectiveness in coherence-based constructivist modalities. Cognitive insight is completely inadequate to the task of transforming the unresolved, compelling emotional themes of a lifetime.
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