by Michael Heller representing the EABP at the EAP Congress, Rome 1997.

 

This paper is written as a basis for discussion in the EAP Training Standards Committee, after many discussions during the 1997 Rome Congress of the EAP.

Contents:

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1. Psychotherapy as a human scientific way of approaching human intimate life

Psycho-logos is the knowledge of the psyche, an attempt to discover what the psyche is through scientific methods. This endeavor will probably take centuries before it can yield useful concrete ways of dealing with human sufferance.

In the meantime, psychotherapies create practical methods to support and understand people who have concrete difficulties. The procedure here is to find helpful rituals, and to report to societies on the damages they have observed, with the hope that changes in social structures could diminish human sufferance. Although psychotherapy does not have the time to proceed scientifically, it advances with a basically scientific attitude:

- Psychotherapy integrates all useful findings produced by research at both an empirical and an epistemological level

- Psychotherapy produces and communicates constructed models of how it proceeds. By constructed models I mean that models are presented as the best possible constructions at a given moment to accomplish a certain task.

- The models produced are formulated in such a way they may help society, individuals, and even psychologists to increase their understanding of human nature.

This empirical strategy has been so effective that psychotherapy is recognised in most countries of the world as one of the major achievements of the 20th century. Psychotherapy is known experientially by as many people as psychology, and arguably has had a far greater impact on our civilisation.

However psychotherapy is more a practical scientific approach of a phenomenon than a science. Indeed psychotherapy presents several differences to other sciences:

- Its greatest institutional originality is that it is the only liberal profession that is not based on an academic faculty. Tax services have recognised this status for half a century. An important part of the work can not be taught in a setting such as what exists today in an academic faculty. The requirement of psychotherapists that they first learn relatively irrelevant knowledge in an academic faculty is an attempt to mask this originality; and a waste of time and energy. With the same costs of time and money, psychotherapists should be requested to learn what they really need to know. Indeed this is the purpose of the EU training standards in the various professions that are now being applied: they are functional criteria. Any deviation from this aim will lower the standards of the profession. One can also point out at the various disciplines that are relevant for a psychotherapist can not easily be grouped into a single current academic faculty.

- Most experimental sciences progress through methodological changes which allows one a more precise mode of data aquisition, and a more refined way of handling data. New models and theories are generated by these new possibilities, or by new formal formulations. In psychotherapy one advances by producing a new point of view, associated to a new ritual. However such a new way of contacting human intimate behavior does not replace the existing ones. For example Bateson' s proposals does not replace Freud's: it shows that to approach human intimacy, several point of views and procedures are required. A new point of view, as for experimental methods, generates new data and models. But a psychotherapeutic theory would require a co-ordination of all the existing approaches.

- Another originality of psychotherapy is that its main instrument is the psychotherapist himself. An unconscious process allows an individual to spontaneously detect interpersonal regulations and to react adequately at an incredible speed (less than half a second). He can detect through repetition of experiences general mechanisms. Through his training he learns (a) how to improve his awareness of how his organism adapts (during his own psychotherapy), and (b) to use his reactions to understand and support others (during supervision). For the moment science is not able to create instruments which can detect what an organism can react to. The capacities of the organism have been designed during human history to detect minute details of behaviour, their meaning, and their place in a given context. It is because we are learning to use ourselves as instruments of research that we are able to perceive in a relevant way aspects of human behaviour in an incredibly refined way. But it is also because individuals and their capacities have not been conceived to be used as research instruments, and to produce helpful behaviours on the demand, that psychotherapists need to help each other constantly in their endeavour. Academia is now attempting to produce psychotherapies that do not require the involvement of personal affects (systemic, behaviour, and cognitive therapies). Although these new therapies are useful, they can not contact the depths explored by the more traditional approaches (Freudian, Jungian, Reichian, etc). Furthermore, one should not confuse the assimilation of academia into science too quickly: the academic psychotherapies are easier to evaluate experimentally because they contact less complex levels of the psyche, but their procedures are not necessarily more "scientific". And the psychologists trained in these techniques are not necessarily well aquainted with the available techniques of psychotherapy.

It is this specific type of knowledge, basically scientific in spirit, but remaining close to practical issues and solutions, which forms the essence of psychotherapy. This approach is fundamentally more a part of the realm of therapeutic crafts rather than that of sciences 1. As in the practice of medicine, which generated psychotherapy, the psychotherapist is inspired by all methods that prove useful. However, he or she will base his/her actions and thinking on scientific knowledge when ever possible. Many areas of a human intimate life have not yet received sufficient attention by research, or are of a complexity that scientific methods can not yet explore. In such cases the psychotherapist will find their inspiration in other existing forms of knowledge. Freud recommended a good familiarity with hypnosis, myths, and history of religions. Relaxation techniques used in some psychotherapies are much more efficient if they can integrate techniques created by yoga, acupuncture, and physiotherapy. For the moment, science is not sufficiently advanced to be the basis for all aspects of the reality approached by psychotherapists.

However, even when using models inspired by non scientific forms of knowledge, psychotherapists are required to reformulate them in a model and form of practice which can be included in the elaboration of the field of psychotherapy.

Such a procedure has two advantages:

A psychotherapy that requires that the patient has a positive view of science, or which cannot enter into empathic contact with the patient's belief, will deprive a lot of citizens from our services.

Psychotherapy can base itself on a known scientific procedure: that of clinical approach, focusing on case studies. A clinical approach is the type of knowledge that a psychotherapist can constructively use. It is also the basis of our present knowledge of psychopathology. Psychopathology is necessary for several reasons other than purely scientific:

- Psychotherapists must be able to define the pathologies that justify the "therapy" half of the word "psychotherapy" .

- They must also be able to know what type of pathologies they can treat, and recognise those types of pathologies that require other forms of treatment. Keeping in psychotherapy a patient who would urgently need another type of treatment can be dangerous for the patient. A well-known example is that of psychotherapists who are not able to recognise emotional difficulties due to cerebral damage. If the brain damage is due to a recent cardio-vascular trauma, for example, the patient might urgently need surgical help rather than an analysis of his anxieties.

- Psychopathology helps one to define a pathology, which allows one to describe a therapeutically relevant change. For example, a person may change completely without changing a tendency to become depressive.

- Insurance policies require that a psychotherapist can differentiate between a psychopathology and current difficulties of existence, and provide an evaluation of what is needed to help a patient.

Thus a basic scientific involvement is central to the ethics of knowledge in psychotherapy. It is however crucial to differentiate psychotherapeutic procedures from that of more experimental procedures, otherwise we could not talk of interactions between the realm of psychotherapy and stricter scientific procedures. Psychotherapy is for the moment one of the most provocative and creative forms of knowledge, but by definition it is situated at the dawn of a scientific approach to the psyche 2.

We can structure our demands on scientific competence in terms of more or less central relevant aspects. The most relevant aspects can be grouped under the heading of "general scientific requirements": demanding that we have a basically scientific ethic of knowledge.

We can then require special competencies in the area where we are expected to be experts, which is in describing case histories, and organizing what we learn from them to produce more effective methods. This already a scientific approach often qualified as "clinical".

Finally we can require that colleges and training schools in psychotherapy are aware of the neighboring disciplines (biological, anthropological and human and social sciences) which have always taken psychotherapeutic discoveries into account, and are slowly providing more and more knowledge which is clearly relevant to our task. However these disciplines are not part of our expertise.

Let us now consider some of these other points in a little more detail.

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2. General scientific requirements

The approach (within psychotherapy) is basically scientific. This means that an approach is clearly a construction that takes into account current available knowledge, and more specific requirements related to a way of approaching patients. Such constructions are clearly related to praxis, and the type of data they are based on needs to be made public. For example; Family Therapy and Body Psychotherapy may have overlapping interests, but they focus on totally different aspects of behavior (communication systems v. psychophysiology).

Practitioners can situate their practice in the history and the scope of their field, and have been trained to view their work critically. This implies a number of points: that they are aware of the benefits and of the limitations of their approach; that they are aware of any contra-indications in that approach; that they are aware of other parallel approaches and their benifits and limitations; and that they are therefore able to direct a patient to the approaches that are best fitted to his or her needs.

Practitioners have been trained to keep and be able to present reasonably accurate and useful case histories and are intellectually able to fit theory to practice and visa versa.


3. A solid basis in clinical research

Analyzing what happens inside and around a patient is the basis of clinical science. Publication of case histories must explicitly state what aspects of behavior have been focused on, and what type of paradigm is used to evaluate these behaviors.

Case histories are the basic data of clinical knowledge. Epistemological options should be clarified through meta-studies of published cases. Thus only published models and cases can be used to justify an approach, and to define it's specificity.

Furthermore there is an urgent need for, and a demand for, properly conducted outcome research, both from within the approach and from studies that compare different approaches. These need to be done critically and objectively, and yet this means that ideally they should not, repreat not, be done by the practitioners of that approach, but by outside researchers. Thereexists a dilemma here as there is currently little interest from academics and researchers outside of psychotherapy in doing this. Currently there have only been a few such studies3 and these have been often contradictory or inconclusive. However much more importantly the protagonists of that approach need these outcome studies to be able to justify the existence and the efficacy of that approach. Such studies should and must be commissioned. This is a task that can be done and should be done and must be done by each of the Training Schools, either collectively or individually.


4. Scientific recognition

Psychotherapists can only recognize each other through discussions based on clinical research, professionalism, and ethical standards, as this is the only type of knowledge they have expertise on. This, as stated, implies a general knowledge of the various models and issues of the field of psychotherapy. It also implies some training on how to discuss the literature, and on the ethics of knowledge.

Psychotherapists should be able to distinguish between the analysis of a personal problem, the analysis of a way of analyzing a person, and the corresponding modes of intervention. There may be several ways of perceiving a problem (or set of problems), and there may be several ways of dealing with such a problem. They should also have the intellectual honesty of admitting their partiality, in that there are relations between how one perceives and how one tends to act. In science, one always talks from a point of view, which is always situated in the realm of a field. This is one of the reasons that the European Certificate for Psychotherapy and other similar professional qualifications demand a post-graduate level of entry into the specialised training: they require some basic intellectual experience, training and understanding in objectivity and relative perspectives.

Practitioners are also required to have a general culture that includes currently available knowledge in neighboring disciplines, as well as the laws and customs of the country they are working in. But these forms of knowledge are not currently part of a psychotherapist's expertise

Furthermore recognition of the main trainers of a particular approach could involve public presentations and publications organized by scientifically recognized institutions, independent from schools (e. g.: EABP, EAP). Also editorial boards consisting of experts in the field must have accepted these presentations. The more respectable the members of a training faculty or an editorial board are, the more respectable the evaluation is. The evaluation criteria of a training faculty or an editorial board depends on the depth of the experience of its members. Objective criteria such as number of years can only partially participate in the evaluation of such boards. We also need to look at criteria for trainers that involve publications; presentations; and similar peer and public acceptances.

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5. Scientific validation

Validations of psychotherapies through experimental methods are to be encouraged. But one cannot require a psychotherapist to have expertise in this domain. Psychotherapists are not trained as experimental scientists. Furthermore, the specificity of each type of approach must be clearly defined. An evaluation made through an experimental approach can only be of the highest interest, but it can not replace an evaluation made through a clinical approach. One can not validate oneself; and an external system of validation can not define what one is.

All branches of psychotherapy and all the various approaches are going to be asked and required for some form of scientific validation. Currently there are no scientific criteria, thankfully. Scientific validation is a very hot topic, politically speaking. There is a spurious form of respectability that attaches itself to scientific validation and a fairly unjustfiable requirement that a particular approach in psychotherapy is required to have scientific validation which is needed for political reasons. This is quoted as necessary to get psychotherapy accepted as an independent profession, and to get the various different approaches accepted, or rejected, as valid approaches in psychotherapy.

Some criteria have been identified for accepting an approach to psychotherapy: as having a proper epistemology; to have been in existence for 'x' years and to be mentioned in various published descriptions of psychotherapy (i.e to be recognised generally); to have 'x' number of practitioners and to be represented in 'x' number of countries (i.e. to be sufficiently present); to have a 'sufficient' number of theoretical papers published and to have a 'scientific' journal (i.e. to have been accepted by one's peers); to agree to the Strasbourg Declaration and to have aims and codes of ethics compatible with EAP (ie. to be acceptable politically); etc. But these are all mostly political and socially acceptable criteria, and are not scientific criteria.

So the scientific criteria question is still wide open.


6. Conclusions

There is also now an open attack from psychologists (particularly in France), publically stating that psychotherapy is something can only be done by psychologists and 130 psychologists have recently been expelled from the French Association for not agreeing to this point of view. The battle lines are now extending to the whole of psychology in Europe at their AGM in Dublin, and one of the tenets of their argument is this question of science.

If psychotherapy is going to be an independent profession in Europe, then psychotherapists have the responsibility of defining the content of their field, their activities and the parameters and the quality of their services. Society has the responsibility of evaluating the usefulness of psychotherapy. We are not the only ones who can evaluate how scientific we are, but we also have the responsibility of defending the type of services that we alone can provide. Much of the responsibility for furthering this question now lies with the various approaches and the training schools. It is they who will now have to provide much of these arguments and do the groundwork, or their particular approach will be marginalised and there is the possibily that the whole of psychotherapy will disappear or be subsumed into psychology, as it is in America, and the chance of a widely varied and independent profession will be lost.


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