A Metamodel of Theories of Psychotherapy: a Guide to Their Analysis, Comparison, Integration and Use Steven J

Clinical Psychology and Psychotherapy Clin. Psychol. Psychother. 10, 1–18 (2003) A Metamodel of Theories of Psychotherapy: A Guide to Their Analysis, Comparison, Integration and Use Steven J. Morris* University of Louisville, KY, USA

Every theory of psychotherapy is composed of a myth and an associated ritual. A myth is a conceptual scheme for explaining clinical problems. A ritual is based upon a myth and is a model of the clinical change process. This article goes far beyond the observation that theories of psychotherapy consist of a myth and a ritual to propose that they share a common underlying structure. The central purpose of this article is to delineate this structure. This structure constitutes a metamodel of theories of psychotherapy. The article shows how the metamodel is a fresh conceptual tool (a) for understanding, analysing, comparing and contrasting, and integrating the basic concepts and principles of theories of psychotherapy and (b) for building case formulations and treatment plans from a theory of psychotherapy. Copyright  2003 John Wiley & Sons, Ltd.

INTRODUCTION It answers the questions: What clinical activities produce therapeutic improvement and how do they Every theory of psychotherapy is composed of work? Succinctly put, theories of psychotherapy a myth and an associated ritual (Frank, 1982).1 include ‘rationale(s) for change, and rituals aimed A myth is a conceptual scheme that provides at facilitating that change’ (Mahoney, 1995, p. 477). an explanation for clinical problems. It is an This article goes far beyond the observation that aetiological model of psychopathology. A myth answers the questions: What are the determinants theories of psychotherapy consist of a myth and a of psychological problems and how do they ritual to propose that they share a common under- develop? A ritual is based upon a myth and is lying structure. The central purpose of this article a model of the clinical change process. A ritual is to delineate the common structure of myths and consists of the psychological methods for treating rituals. This hypothetical structure constitutes a clinical problems together with their rationale. metamodel of theories of psychotherapy. By delin- eating the structure of theories, the metamodel provides a framework for analysing, comparing * Correspondence to: Steven J. Morris, Department of Educa- and contrasting, and integrating the basic con- tional and Counseling Psychology, University of Louisville, cepts and principles of theories of psychotherapy. Louisville, Kentucky 40292, USA. E-mail: [email protected] In addition, the metamodel provides a framework 1 The words ‘‘myth’’ and ‘‘ritual’’ are used advisedly to for constructing case formulations and treatment emphasize that, although typically expressed in scientiﬁc plans for any theory of psychotherapy. terms, therapeutic rationales and procedures cannot be In the next section I present an analysis of the disproved’ (Frank, 1982, p. 20). In adopting Frank’s words, structure of myths and rituals—the metamodel. I do not intend to disparage theories as false or imaginary, but to convey the idea that they represent different visions After presenting the metamodel, I illustrate its of reality. utility for understanding theories of psychotherapy

Copyright  2003 John Wiley & Sons, Ltd. Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/cpp.351 2 S. J. Morris by applying it to four prominent theories. Next, I as well as verbal behaviour and overt motor show how the metamodel generates a systematic behaviour), thinking and feeling that are associated method for constructing a case formulation and a with distress or impairment (Corsini, 2000; Persons, treatment plan from a theory of psychotherapy. 1989; Persons & Tompkins, 1997; Stevens & Morris, Finally, I discuss the unique contributions that 1995; Strupp, 1988). Consistent with this char- the metamodel makes to understanding and using acterization of psychological problems, the goals theories of psychotherapy. of psychotherapy consist of changing how clients think, feel and behave (Cormier & Cormier, 1999; Corsini, 2000; Frank & Frank, 1991; Persons, 1989; THE METAMODEL Persons & Tompkins, 1997; Prochaska & Norcross, 1999; Stevens & Morris, 1995; Strupp, 1988). Thus, The Structure of Myths psychological problems and treatment goals can be Myths consist of three chained components: psy- described in terms of their cognitive, affective and chological problems, dysfunctional personal char- behavioural components (Persons, 1989; Persons & acteristics, and the origins of these personal char- Tompkins, 1997; Stevens & Morris, 1995). For exam- acteristics. The upper panel of Figure 1 depicts ple, the ‘academic problems’ of a college student the relationship between the three components of might include difficulty in concentrating (a cogni- myths. The solid arrow represents the causal rela- tive deficit), test anxiety (a negative mood), and tionship (‘process’) between dysfunctional personal procrastination (a maladaptive behaviour). This characteristics and psychological problems and the perspective on psychological problems is compati- broken-line arrow represents the contributory role ble with the approach to defining mental disorders that the origin plays in the development of personal used in the Diagnostic and Statistical Manual of Men- characteristics. tal Disorders, fourth edition (DSM-IV-TR, American Psychological problems are any conditions that Psychiatric Association, 2000). ‘Most DSM disor- merit clinical attention. In rational emotive behav- ders are clusters of correlated symptoms at a iour therapy (REBT; Ellis, 1994, 2000), for example, syndromal level... A syndrome is a group or pat- inappropriate emotions (emotional upsets) and tern of symptoms, affects, thoughts, and behaviors self-defeating behaviours are the primary cate- (italics added) that tend to appear together in clin- gories of psychological problems. At the most basic ical presentations’ (Frances, First, & Pincus, 1995, level, psychological problems consist of patterns pp. 16–17). For example, fear (a negative mood) of behaving (including physiological responses and avoidance (a maladaptive behaviour) figure

Figure 1. The structure of myths and rituals

Copyright  2003 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 10, 1–18 (2003) A Metamodel of Theories of Psychotherapy 3 prominently in the definition of the various anxi- Ellis (2000) characterized the goals of psychother- ety disorders. apy: ‘REBT is not just oriented toward symptom Theories differ in how they portray psychological removal... The usual goal of REBT is to help problems and the corresponding goals of treatment. people reduce their underlying symptom-creating Consistent with the metamodel, some theories con- propensities’ (p. 170). From the perspective of the strue psychological problems as symptoms, or metamodel, these ‘symptom-creating propensities’ overt difficulties in thinking, feeling and behaving. are the immediate causes of psychological prob- These theories are often contrasted with theories lems—not the problems per se. that construe psychological problems as disor- In the metamodel, dysfunctional personal character- ders of personality or character (Messer & Wach- istics are the immediate determinants, or causes, of tel, 1997). For example, psychodynamic theories psychological problems. Theories of psychotherapy (like Freudian psychoanalysis) reject a characteri- posit that particular characteristics of the individ- zation of psychological problems that emphasizes ual cause psychological problems or psychopatho- overt difficulties (i.e. symptoms). Rather, they view logical conditions. These personal characteristics symptoms as the symbolic expression of an under- are central personality constructs in the theories. lying problem (disease) not the problem itself. By For example, REBT (Ellis, 2000; Ellis & Harper, contrast, behavioural theories portray symptoms 1997) posits that irrational beliefs are the cause as the problem. Consequently, symptom-focused of psychological problems (emotional upsets and theories conceive the goals of psychotherapy as self-defeating behaviour). Irrational beliefs have a a matter of symptom relief, whereas personality- quality of demandingness, magically insisting that focused theories conceive the goals as a matter the universe should, ought, or must be as the per- of personality reorganization or characterologi- son wishes it to be (Ellis, 2000; Ellis & Harper, 1997). cal change (Frank, 1987; Messer & Wachtel, 1997; One example is the idea that ‘I MUST be approved or accepted by people I find important!’ This belief Yalom, 1995). However, these two perspectives are can lead to anxiety or depression. not as disparate as is commonly regarded. After all, In addition to identifying problem-creating per- personality refers to distinctive, stable and endur- sonal characteristics, a myth provides an account ing patterns in thinking, feeling, and behaviour of how these characteristics produce psychological (Mischel, 1993; Pervin, 1996). Accordingly, person- problems. That is, a myth posits a causal process ality reorganization ultimately involves changes in by which the personal characteristics produce the patterns of thinking, feeling and behaving. The problems. The causal process is expressed as propo- two perspectives do differ in that the personality- sitions explaining how dysfunctional personal char- focused theories emphasize more pervasive and acteristics lead to psychological problems. This pro- global patterns in thinking, feeling, and behaviour, cess might involve a diathesis-stress model with the whereas the symptom-focused theories emphasize dysfunctional personal characteristics serving as a more specific and circumscribed patterns (Corey, diathesis (stable vulnerability factor) and identified 2001; Frank, 1987). events serving as stressors that activate the per- Even when a theorist argues that the crux of a sonal characteristics. The underlying psychological psychological problem is some underlying pathol- mechanism consists of the hypothesized personal- ogy (e.g. an unconscious conflict), this pathology ity characteristics (constructs) together with the is a problem only because it is manifested in overt hypothesized process (in the form of a nomologi- difficulties or symptoms. If there were no overt dif- cal network) that explains how these characteristics ficulties associated with the underlying ‘pathology’, lead to psychological problems. To illustrate, REBT there would be no psychological problem. Accord- (Ellis, 1994, 2000) uses the ABC formula to explain ing to Freud (1926/1989), everyone defends against how irrational beliefs lead to psychological prob- unbearable ideas, but what distinguishes ‘neu- lems. According to this formula, in emotional rotics’ is that their defences produce symptoms. disturbances Activating events are always inter- People seek treatment because of distressing and preted in terms of irrational Beliefs and interpreting debilitating thoughts, feelings, and behaviours, not current Activating events in terms of ‘demanding’ because of some hypothesized underlying pathol- irrational Beliefs inevitably produces dysfunctional ogy. From the perspective of the metamodel, the Consequences (emotional upsets and self-defeating underlying pathology is viewed as the cause of behaviours). Consider a woman who holds the the psychological problem not the problem itself. belief that ‘I MUST be approved or accepted by To illustrate this subtle distinction, consider how people I find important!’ She might interpret a fight

Copyright  2003 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 10, 1–18 (2003) 4 S. J. Morris with her sister as ‘awful’ or ‘terrible’ and become goals are described in terms of patterns in think- depressed as a result. ing, feeling and behaviour (Cormier & Cormier, The origin is an account of the genesis of dys- 1999; Corsini, 2000; Frank & Frank, 1991; Persons functional personal characteristics. It specifies the & Tompkins, 1997; Prochaska & Norcross, 1999; nature of the life circumstances or learning experi- Strupp, 1988). REBT, for example, construes psy- ences that contribute to the development of those chological problems to consist of emotional upsets personal characteristics that are presumed to cause and self-defeating behaviour, and it construes the psychological problems. Although the origin may treatment goal to be their elimination. As defined include genetic or biological influences, theories of here, treatment goals are very close to Rosen psychotherapy tend to emphasize the role of nur- and Proctor’s (1981) concept of ultimate outcomes, ture rather than nature. The origin may involve which ‘address the reason for which treatment is a theory of personality development (e.g. Freud’s undertaken and reflect the objectives toward which theory of psychosexual development) or principles efforts are to be directed’ (p. 419). of learning (e.g. Wolpe, 1982). REBT (Ellis, 1994, Revised personal characteristics are the hypothe- 2000) postulates that physiology (innate tenden- sized changes that occur within a client as a result cies to think irrationally), cultural messages and of clinical intervention and that lead to clinical familial messages contribute to the development of improvement in thinking, feeling and behaving. irrational beliefs. The underlying premise is that clinical improvement results from modifying those dysfunctional personal characteristics that are responsible for psy- The Structure of Rituals chological problems. Thus, dysfunctional personal characteristics serve as the treatment targets that are Theories of the aetiology of psychopathology are to be revised by interventions. In REBT, for exam- fruitful sources for developing theories of the clin- ple, the revised personal characteristics involve the ical change process. As Frank (1982) noted, rituals substitution of rational beliefs (or the adoption of are derived from myths. Indeed, the structure of a rational philosophy) for pathology-inducing irra- rituals (depicted in the lower panel Figure 1) paral- tional beliefs. lels the structure of myths. The three components Revised personal characteristics are similar to of rituals are linked to counterparts in myths: Rosen and Proctor’s (1981) concept of instrumental treatment goals involve the undoing of psycho- outcomes, those effects of intervention that ‘serve logical problems, revised personal characteristics as the instruments for the attainment of other out- involve the undoing of dysfunctional personal char- comes’ (p. 419), notably ultimate outcomes. Instru- acteristics, and interventions undo the effects of mental outcomes typically represent variables that the origin. As Figure 1 shows, interventions work are hypothesized to be causally linked to ultimate by revising dysfunctional personal characteristics. outcomes (Nezu & Nezu, 1993). The distinction Revised personal characteristics serve as mediators between ultimate outcomes and instrumental out- (or mechanisms) of change. Presumably, interven- comes parallels the distinction between treatment tions result in revised personal characteristics that goals and revised personal characteristics. This dis- in turn result in the amelioration of psychological tinction is very important for the clear explication problems—the treatment goal. The solid straight of theories. In discussions of theories, revised per- arrows in Figure 1 represent the causal relation- sonal characteristics (instrumental outcomes) are ships between interventions and revised personal often confused with the treatment goals (ultimate characteristics and between revised personal char- outcomes). To illustrate, insight is erroneously acteristics and treatment goals. presented as the goal of some theories of psy- Treatment goals are the desired clinical outcomes chotherapy (Weiner, 1975). From the perspective and are defined vis-a-vis` psychological problems of the metamodel, insight is a revision in a per- (Kanfer & Busemeyer, 1982). The aim of therapy sonal characteristic (or an instrumental outcome) is to move clients from their current psycholog- not a treatment goal (or an ultimate outcome). As ical condition (the psychological problem) to a Weiner (1975) suggested, insight is a means to an desired condition (the treatment goal). For exam- end not an end in itself. Many people lack insight ple, if recurring and unexpected panic attacks are without suffering psychological impairment or dis- the problem (current psychological condition), then tress. Therapists foster insight because they believe freedom from panic attacks is the treatment goal that doing so will reduce psychological problems (desired condition). Like psychological problems, and restore mental health.

Copyright  2003 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 10, 1–18 (2003) A Metamodel of Theories of Psychotherapy 5

How does therapy promote therapeutic revisions the metamodel and to demonstrate its utility as in dysfunctional personal characteristics? That is, a guide to theories. My purpose is not to present how does therapy achieve instrumental outcomes the theories in detail, but to illustrate how the that, in turn, lead to ultimate outcomes? It does metamodel maps out the essential structure of so by providing corrective learning experiences theories and in so doing illuminates them. The (Goldfried, 1980, 1988; Strupp, 1988). ‘All psy- presentation of each theory is streamlined and chotherapies are methods of learning’ (Corsini, simplified, but adequate for the purpose at hand. A 2000, p. 6; see also Goldfried, 1988; Strupp, 1988). number of excellent texts (e.g. Corey, 2001; Corsini, Interventions are the learning experiences or condi- 2000; Ford & Urban, 1998; Patterson & Watkins, tions that the therapist arranges because they are 1996; Prochaska & Norcross, 1999) provide more presumed to change those dysfunctional personal comprehensive accounts of the theories. Obviously, characteristics that produce the client’s psycho- the most comprehensive treatment of a theory is to logical problems. From the perspective of REBT, be found in the writings of the author of the theory. treatment is an educational process involving persuasion and confrontation. A central technique is to Psychoanalysis (Freud) dispute clients’ irrational beliefs and to teach them to do so by themselves. Presumably, disputation The myth of Freudian psychoanalysis is well leads clients to revise or abandon their pathology- known. According to Freud, neuroses arise out of producing irrational beliefs, leaving rational beliefs unconscious conflicts involving forbidden sexual or in their place. aggressive wishes of the id and restraining forces Interventions encompass all the strategic actions of the ego and the superego. The ego would risk of the therapist, including general listening and danger (punishment) and overwhelming anxiety interviewing behaviour, theory-based techniques, if the forbidden wishes (or ‘unbearable ideas’; and the therapeutic relationship itself. Theories Fine, 1979) were represented in consciousness and vary in the interventions they prescribe. For exam- directly expressed. Consequently, the ego erects ple, theories offer different prescriptions for using defences that inhibit conscious expression of the the therapeutic relationship as a vehicle for correc- id’s wishes (i.e. repression) and which transform tive learning experiences (Gelso & Carter, 1985). these wishes into symbolic disguises. This results Theories also vary in how they conceptualize the in symptoms that serve as a defence against learning process (i.e. how interventions lead to unacceptable wishes and, in many cases, an indirect changes in behaviour, cognitions and feelings). The expression, or gratification, of these same wishes. same intervention may be conceptualized differ- ‘The symptoms of neuroses are, it might be said, ently by different theories. For example, exposure without exception either a substitutive satisfaction therapy for treating anxiety disorders looks one of some sexual urge or measures to prevent such way through the lens of social cognitive theory a satisfaction; and as a rule they are compromises (Bandura, 1986) and another way through the lens of the two’ (Freud, 1940/1969; p. 43). Symptoms of implosive therapy (Levis & Hare, 1977). Viewed are the symbolic manifestation of the unconscious through the lens of social cognitive theory, expo- conflict involving a forbidden wish (or unbearable sure provides information that enhances the client’s idea). From a psychoanalytic perspective, the self-efficacy expectation of being able to handle the symptoms of hysteria reduce anxiety by resolving anxiety-provoking situation. Viewed through the an internal conflict between forbidden wishes and lens of implosive therapy, exposure involves the superego injunctions (e.g. paralysis of the arm to extinction of a conditioned anxiety response. prevent hitting one’s father); and the symptoms of hysteria are compromise formations that express both a wish and a punishment and keep the conflict out of consciousness. In addition to symbolizing the THE METAMODEL APPLIED TO FOUR particular conflict that underlies them, symptoms THEORIES OF PSYCHOTHERAPY deplete the neurotic’s store of psychic energy. Neurotics are unable to enjoy life and to function In this section, I apply the metamodel to four adaptively because their ego is weakened and prominent and familiar theories of psychotherapy: drained of the energy required to defend against Freudian psychoanalysis, Roger’s person-centred forbidden wishes. therapy, Wolpe’s behaviour therapy, and Beck’s According to the Freudian myth, the roots of cognitive therapy. This exercise serves to illustrate adult neuroses are found in childhood experiences.

‘It seems that neuroses are acquired only in interpretations, the analyst provides the patient early childhood (up to the age of six), even with the unconscious meaning of material revealed though their symptoms may not appear until in free associations, dream reports, symptoms, much later’ (Freud, 1940/1969; p. 41). Indeed, Freud resistance, and transference. Interpretation is a (1926/1989) claimed ‘Signs of childhood neuroses means of illuminating an unconscious conflict and can be detected in all adult neurotics without tracing it back to its origin in childhood. Thus, exception’ (p. 80). Specifically, the unconscious interpretations are intended to help patients gain conflicts underlying adult neuroses involve the insight into the unconscious conflicts that are the revival of childhood conflicts from pregenital stages source of their problems. of psychosexual development (Arlow, 2000). In The myth and the ritual of psychoanalysis are the face of a precipitating event (e.g. attempted summarized in Figure 2. The origin of psycholog- seduction by a married friend), the adult neurotic ical problems consists of early childhood experi- re-experiences at an unconscious level an earlier ences that result in fixations. These fixations leave childhood conflict (e.g. a struggle between a desire the adult vulnerable to regression to a state of for taboo sex with the opposite sex parent and the mind that echoes childhood neuroses. This state fear of punishment). In sum, childhood experiences of mind consists of unconscious conflicts involv- and resultant fixations leave the adult neurotic ing defences against unbearable ideas (forbidden vulnerable to regression to these past ego states wishes). The unbearable ideas arouse anxiety that of childhood conflict (Giovacchini, 1987). sets the defences in motion. Unconscious conflicts The Freudian ritual is derived from this under- are the dysfunctional personal characteristics that standing of neuroses. The mechanism of change are at the root of neurotics’ psychological prob- consists of patients’ insight into their underlying lems (i.e. symptoms). The ego’s defences against unconscious conflicts. If the repressed wish—the unbearable ideas are manifested in symptoms that unbearable idea at the root of neurotic symp- symbolize the unconscious conflict. Now consider toms—could be made available to consciousness the Freudian ritual. The interventions of the analyst, and to the conscious control of the ego, the symp- especially interpretation, promote insight, an undo- toms become unnecessary and disappear. The ing of the unconscious conflict. Insight—making analyst’s ‘knowledge’ makes up for the patient’s the unconscious conscious—leads to symptom ‘ignorance’ and gives the patient’s ‘ego back its relief as well as to personality reorganization (i.e. mastery over lost provinces of his (sic) mental enhanced ability to love and to work). life’ (Freud, 1940/1969, p. 30). With access to the repressed material, the adult ego can resolve the Person-Centred Therapy (Rogers) unconscious conflict that overwhelmed the help- less, immature ego of childhood. Thus, clinical According to Rogers (1951, 1959), the development improvement comes from making the unconscious of psychological problems (maladjustment) is a conscious so that ‘Where id was, there shall ego be’ story of socialization gone awry. The basic story (Freud, 1933/1964; p. 80). is simple. As children, clients come to realize Treatment goals include a reorganization of per- that to earn parental love, they must act—they sonality that goes beyond mere symptom relief. must be—precisely as their parents wish. As a As symptoms abate and drain less of its energy, result, they develop a falsified self, disowning theinvigoratedegofindsmoreadaptivewaysof aspects of themselves that jeopardizes the love dealing with life’s demands. This results in per- and approval of their parents and others important sonality reorganization with the patient exhibiting in their lives. They then defend this falsified self more deliberate, realistic control of affect, thought against experiences that contradict it. The result is and action (Ford & Urban, 1998). The ideal goal is a psychological maladjustment. mature genital personality, expressed in the ability A more complete and rigorous account of the to love altruistically and to work productively. Rogerian myth goes as follows. All people have The techniques of psychoanalysis aim to uncover a compelling need for positive regard (a need the underlying unconscious conflict and its origins. for love, respect, approval, affection and so on). Free association (reporting whatever comes to mind This need renders people vulnerable to the influ- without censorship) is the primary method for gain- ence of others, notably their parents. Out of the ing access to unconscious material (Auld & Hyman, need for positive regard, people develop a need 1991). The principal technique of treatment is inter- for self-regard (a need to like oneself independent pretation (Giovacchini, 1987; Greenson, 1967). With of the attitudes of others). These two needs are

Copyright  2003 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 10, 1–18 (2003) A Metamodel of Theories of Psychotherapy 7

Figure 2. The myth and the ritual of psychoanalysis (Freud) universal and compelling. What sets the stage for worth (i.e. they are symbolized in distorted form in maladjustment is conditional positive regard (when consciousness) or they are denied symbolization in others impose conditions that children must fulfil in awareness. Courtney is able to accurately perceive order to be loved). When parental regard is condi- instances when she behaves ‘nicely’, but she denies tional, rather than unconditional, children introject genuine feelings of anger or she distorts them (e.g. their parents’ conditions of worth, making them perceiving unfair treatment as her own fault). Out of their own. Self-regard becomes contingent upon their symbolizations of their experience—accurate fulfilling these internalized conditions of worth as well as distorted—people construct a self (a self- and a person feels worthy only when acting in concept or conscious view of the self). Because some accord with these conditions. Consider the case of experiences are distorted or denied symbolization, Courtney whose parents always insisted on ‘nice’ the constructed self is false. In Roger’s terms there behaviour. Because of her introjected conditions of is incongruence between experience (what the per- worth (‘I must be nice’), Courtney feels good about son genuinely experiences, for example, feels) and herself, feels lovable and worthy, only when she the self (what is symbolized as part of the self). For is agreeable and ‘nice’, not when she is angry and example, Courtney views herself as a ‘nice’ person assertive. In order to feel good about themselves who is incapable of anger—even though she does people deny or distort organismic experiences that at times feel angry. The incongruence between self violate their conditions of worth. ‘Because of the and experience is the cause of psychological mal- need for self-regard, the individual perceives his adjustment. If a person were to become aware of (sic) experience selectively, in terms of the condi- incongruent experiences, their self-concepts would tions of worth which have come to exist in him’ be threatened, their conditions of worth would (Rogers, 1959, p. 226). People accurately perceive be violated, their need for self-regard would be and symbolize in awareness those experiences and compromised, and they would be flooded with behaviours that accord with conditions of worth. anxiety. Defences, including symptoms, develop As for experiences that contradict conditions of to keep these threatening experiences (i.e. experi- worth, they are distorted to fit their conditions of ences incongruent with the self) from awareness,

Copyright  2003 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 10, 1–18 (2003) 8 S. J. Morris thereby preventing the painful consequences of result in incongruence between self and experi- such awareness. Defences involve the distortion or ence—the immediate determinant of psychological denial of experience. ‘Defensive behaviours include problems. The process that links incongruence with not only the behaviours customarily regarded as the psychological problems begins with anxiety. neurotic—rationalization, compensation, fantasy, Anxiety is aroused by the prospect that experiences projection, compulsions, phobias, and the like—but that are incongruent with the self will enter con- some of the behaviours customarily regarded as sciousness. This activates the process of defence psychotic, notably paranoid behaviours and per- that keeps these experiences out of consciousness haps catatonic states’ (Rogers, 1959, pp. 227–228). and in so doing protects the self. The resulting More serious psychological problems arise when defensive behaviours are one form of psychologi- the process of defence is unsuccessful. When this cal maladjustment. The other form is disorganized happens, the person becomes aware of the incon- behaviour, which arises when the defences break gruent experience. This shatters the self and leads down. The ritual identifies a necessary and suffi- to a state of disorganization. ‘The disorganized cient intervention for therapeutic improvement: a category includes many of the ‘‘irrational’’ and therapeutic relationship characterized by uncondi- ‘‘acute psychotic behaviors’’ ’ (Rogers, 1959, p. 228). tional positive regard, empathy and genuineness If Courtney were to become aware of her long (the core conditions). This relationship fosters con- denied anger, she would suffer panic and psycho- gruence between self and experience as well as logical disintegration. dissolution of the conditions of worth. This leads to The path toward psychological adjustment, the psychological adjustment (openness to experience path of person-centred therapy, involves the devel- and less defensive behaviour). opment of a self, which is congruent with experience (along with the dissolution of conditions Behaviour Therapy (Wolpe) of worth). The therapeutic relationship provides the necessary and sufficient conditions for mov- All approaches to behaviour therapy are built upon two fundamental assumptions. The first assump- ing in this direction (Rogers, 1957). ‘If the therapist tion is that learning is the basis of the development is successful in conveying genuineness, uncondi- and the treatment of psychological problems. The tional positive regard and empathy, then the client second assumption is that psychological prob- will respond with constructive changes in person- lems and treatment goals consist of behavioural, ality organization’ (Raskin & Rogers, 2000). Thus, cognitive and affective responses to specific situa- the person-centred therapist communicates accep- tions. Consistent with these assumptions, Wolpe’s tance and understanding of clients as they reveal theory (1982) emphasizes classical conditioning themselves in counselling. In the safety of this ther- (and unconditioning) of unadaptive anxiety (or apeutic relationship, the client comes to accurately fear) responses. symbolize in consciousness those experiences that Wolpe’s (1982) theory deals only with neuroses. were previously denied or distorted. Once these By neuroses Wolpe (1982) meant ‘a persistent experiences become conscious, the self is gradu- unadaptive habit that has been acquired by learning ally revised and expanded to include them, giving in an anxiety-generating situation (or succession of rise to increasing congruence between the self and such situations) and in which anxiety is usually the experience. This results in psychological adjust- central component’ (pp. 9–10). Inappropriate fears, ment. Psychological adjustment is synonymous particularly social fears, are most common. Once with openness to experience which is ‘the polar anxiety becomes a conditioned response to specific opposite of defensiveness’ (Rogers, 1959, p. 206). stimuli, it often has secondary effects (or symptoms) It is reflected in increased spontaneity, less defen- that cause suffering including stuttering, shyness, siveness, more realistic perceptions, more effective sexual dysfunction, exhibitionism, kleptomania, problem solving, decreased anxiety, enhanced con- fetishism, substance abuse, neurotic depression, fidence and self regard, and greater acceptance of obsessions and compulsions. Wolpe’s theory specif- others (Rogers, 1959). ically excludes organically-based disorders (e.g. Figure 3 summarizes the Rogerian myth and rit- psychotic illness) because they are not learned and, ual. The origin is conditional positive regard in therefore, not amenable to behavioural treatment. conjunction with the universal needs for positive Neurotic anxiety (or fear) is the core of all regard and self-regard. Conditional positive regard neuroses and is established through learning. leads to introjected conditions of worth, which It is a product of classical conditioning or of

Copyright  2003 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 10, 1–18 (2003) A Metamodel of Theories of Psychotherapy 9

Figure 3. The myth and the ritual of person-centred therapy (Rogers) misinformation (cognitive learning). In either case, be made to occur in the presence of the anxiety- neurotic anxiety is a reaction to a stimulus situation evoking stimuli, it will weaken the bond between that is not objectively a source or a sign of danger. these stimuli and anxiety’ (Wolpe, 1973, p. 17). With (For the sake of simplicity, I will ignore cognitively- enough pairings of the anxiety-inhibiting response based neurotic anxiety in the following analysis.) with the anxiety-eliciting stimuli, the maladaptive The classical conditioning of neurotic anxiety may anxiety response is eliminated, as are the secondary result from a single event (single-trial learning) or it effects that flow from it. may be progressively built up over the course of a Figure 4 summarizes the myth and the ritual series of related events. These learning experiences of Wolpe’s theory. The origin of patients’ prob- strengthen a stimulus–response bond (i.e. a bond lems can be traced to their conditioning histories, between the conditioned stimulus and the condi- which establish bonds between conditioned stimuli tioned response of anxiety), which is coded in func- and conditioned anxiety responses. These stimu- tional connections formed between neurons. There lus–response bonds are the personal characteristics is specificity in these stimulus–response bonds. that are the immediate determinants of psycho- Thus, behaviour problems (neuroses) involve con- logical problems. Conditioned stimuli trigger the ditioned anxiety that is highly specific in both the conditioned neurotic anxiety responses that lead stimuli that elicit it and in the consequences that to secondary symptoms. These unadaptive habits follow from it. (neurotic anxiety as well as its secondary effects) This analysis of neuroses implies that success- are the psychological problems that patients suffer. ful treatment requires the elimination of spe- To treat these problems, the behaviour therapist cific anxiety responses. Because anxiety responses first identifies precisely what stimuli trigger the are learned through conditioning, they can be neurotic anxiety responses and then arranges coun- unlearned through counterconditioning. Counter- terconditioning experiences to weaken the bonds conditioning is based upon the principle of recipro- between these stimuli and the anxiety responses. cal inhibition: ‘if a response inhibiting anxiety can This weakens or eliminates the unadaptive habits.

Figure 4. The myth and the ritual of behaviour therapy (Wolpe)

Cognitive Therapy (Beck) events. Schemas are tacit assumptions that people use to understand their experiences. They Cognitive therapy (Beck, 1991; Beck, Freeman, & are the ‘meaning-making structures of cognition’ Associates, 1990; Clark, Beck, & Alford, 1999) (Alford & Beck, 1997, p. 15). When a schema is emphasizes the role of dysfunctional thinking in activated, a person interprets information in terms psychological disorders. Presumably, if thinking of that schema. As information (including memo- goes askew, then so do feelings and actions. ‘As ries) is processed, it is biased or distorted to fit the ye think, so shall ye feel and act’. It follows activated schema. This biased processing results that treatment provides symptomatic relief by in schema-consistent interpretations or automatic correcting dysfunctional thinking. thoughts. ‘Cognitive distortions are evident in auto- As a vehicle for presenting the myth and the matic thoughts’ (Beck & Weishaar, 2000, p. 254). For ritual of cognitive therapy, consider the following example, David viewed his failing grade through scenario. Two college students, David and Paul, the lens of his ‘incompetence schema’ and conse- earn an ‘F’ on their first paper in freshmen rhetoric. quently interpreted it as another instance of his David attributes his failing grade to his inferior abil- stupidity. Paul viewed his failing grade through ity (‘I’m too stupid for college’), becomes despon- the lens of his ‘mistrust schema’ and interpreted it dent and withdraws from the world. Paul attributes accordingly. In sum, when schemas are activated, his failing grade to an unfair professor (‘The profes- they are used to interpret information, yielding sor wants to screw me over!’), becomes angry, and schema-consistent automatic thoughts that lead to verbally assaults the professor. This scenario illus- consistent feelings and behaviours. trates a fundamental postulate of cognitive therapy: Psychopathology results from dysfunctional sche- individuals’ interpretations of a situation rather mas constructing ‘maladaptive meanings’ (i.e. dys- than the objective situation per se determine their functional automatic thoughts) about the self and emotional and behavioural responses. Beck refers the world (Alford & Beck, 1997). ‘Psychologi- to these spontaneous interpretations (e.g. ‘I’m too cal disorders are characterized by dysfunctional stupid for college’) as automatic thoughts. Why thinking derived from dysfunctional beliefs’ (Beck, did David and Paul have different interpretations 1997, p. 56). Indeed, each psychological disorder is of their objectively identical situations? An answer associated with a unique cognitive profile with a can be found in a second postulate of cognitive characteristic theme in the dysfunctional schemas therapy: individuals’ schemas (beliefs about the and allied automatic thoughts about the self, the self and the world) shape their interpretations of world and the future. For example, depressed

Copyright  2003 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 10, 1–18 (2003) A Metamodel of Theories of Psychotherapy 11 patients’ interpretations of their experiences are and the patient become co-investigators who sys- shaped by characteristic beliefs such as ‘I am tematically gather and examine the evidence for or incompetent’, ‘I am worthless’, or ‘I am unlov- against the patient’s cognitions. They regard auto- able’. Paranoid patients’ automatic thoughts about matic thoughts and schemas as testable hypotheses their experiences reflect other beliefs such as ‘You and they employ the scientific method of hypothesis can’t trust anybody’, ‘It’s a cruel world’, or ‘I’m testing to evaluate their validity and utility. For always mistreated’. The characteristic automatic example, the therapist helps patients to design thoughts of a particular disorder lead to its char- behavioural experiments to test the validity of acteristic affective and behavioural symptoms. For their thoughts and beliefs. When therapists employ example, David reacted to his failing grade as a behavioural techniques, they view them as meth- depressed patient might, interpreting it as a sign ods for helping patients to test and disconfirm their of his incompetence which gave rise to symp- faulty interpretations and beliefs (e.g. exposure toms including sadness, a sense of worthlessness treatments viewed as involving experiences that and anhedonia. Paul’s suspicious thinking and the disconfirm unwarranted fears). David’s cognitive other symptoms it generated (e.g. anger, counterat- therapist might arrange graded task assignments tacking) are characteristic of a paranoid personal- to provide successful experiences that would dis- ity disorder. confirm David’s incompetence schema. Cognitive therapy posits that change in dysfunc- Figure 5 summarizes the Beckian myth and rit- tional automatic thoughts and schemas is critical ual. Life experiences shape the development of to symptomatic relief. ‘Improvement results from dysfunctional schemas. As people interact with the modification of the dysfunctional thinking and environment, they construct these meaning-making durable improvement from modification of beliefs’ structures to comprehend and adapt to the world. (Beck, 1997, p. 56). Therapeutic interventions are Although Beck emphasizes the role of a person’s designed to identify, reality-test, and correct dis- learning history (particularly, negative experiences torted automatic thoughts and the dysfunctional with caregivers in childhood) in the develop- schemas that generate these thoughts. The therapist ment of dysfunctional schemas, he acknowledges

Figure 5. The myth and the ritual of cognitive therapy (Beck)

Copyright  2003 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 10, 1–18 (2003) 12 S. J. Morris that biology also plays a role. As Figure 5 shows upon the premise that a case formulation is an dysfunctional schemas are the personal characteris- instantiation of a myth in that a case formulation tics that generate maladaptive thoughts, emotions particularizes the concepts and principles of a the- and behaviours. When dysfunctional schemas are ory’s myth to a specific client. To illustrate, the activated, they guide the processing, or interpreta- myth of REBT maintains that irrational beliefs are tion, of information. Schematic (meaning) process- the causes of emotional upsets. In developing a case ing biases information to conform to the content of formulation of a particular client, an REBT thera- the schema. This results in schema-consistent auto- pist would need to identify the client’s particular matic thoughts (interpretations). These dysfunc- emotional upsets (e.g. depression) and the partic- tional automatic thoughts are cognitive symptoms ular irrational beliefs that give rise to them (e.g. ‘I that lead to specific affective and behavioural symp- MUST be approved by people I find important!’). toms. Psychological problems are construed as Because a case formulation is an instantiation of maladaptive thoughts, emotions, and behaviours. a myth, the format of case formulations parallels They are often packaged in the language of the stan- the structure of myths: (1) a list of psychological dard psychiatric syndromes of DSM-IV. Indeed, problems, (2) the dysfunctional personal character- Beck and his colleagues have attempted to iden- istics that are hypothesized to cause or maintain tify the cognitive profiles associated with various the problems, (3) the hypothesized process that psychiatric disorders. explains how the dysfunctional personal charac- The Beckian ritual maintains that the modification teristics cause the problems, and (4) the origin of of dysfunctional schemas leads to cognitive, emo- the dysfunctional personal characteristics. This for- tional and behavioural improvement (i.e. symptom mat (cf. Persons & Tompkins, 1997) lends itself to relief). The treatment goal is to reduce the patient’s a systematic four-step process of case formulation cognitive, emotional and behavioural symptoms. that is outlined in Figure 6. The steps consist of To accomplish this, cognitive therapists arrange answering four questions: specific learning experiences to teach patients to identify, evaluate, and alter dysfunctional auto- (1) What particular psychological problems does matic thoughts and schemas. this client face? In answering this question, the therapist lists the client’s overt difficulties in thinking, feeling and behaving (Persons, 1989; Persons & Tompkins, 1997). A psychiatric CASE FORMULATIONS AS diagnosis might be used to characterize the INSTANTIATIONS OF MYTHS overt difficulties or symptoms. As noted earlier, A case formulation (or case conceptualization) is an theories vary in how they construe psycholog- individualized model of the mechanisms that cause, ical problems; for example, as symptoms of control, or maintain a particular client’s psycholog- unconscious conflicts (Freud), as defensive or ical problems (Eells, 1997c; Meier, 1999; Persons, 1989; Stevens & Morris, 1995). A sound case formulation is vital in therapy because selecting an appropriate treatment requires an understanding Case Formulation (based on the myth): of what is causing or maintaining a client’s prob- 1. Identify the client’s specific psychological lems (Eells, 1997a; Eells, Kendjelic, & Lucas, 1998). problems In other words, a treatment plan is based directly 2. Develop hypotheses about the client’s dysfunctional personal characteristics upon a case formulation (Eells, 1997c; Meier, 1999; 3. Develop a working model the process whereby Persons & Tompkins, 1997). There are a variety of these dysfunctional personal characteristics give systematic methods for constructing case formula- rise to the client’s psychological problems tions (see Eells, 1997b). These methods are based 4. Identify the origin of the client’s dysfunctional upon a guiding theory and show how to use the personal characteristics concepts and principles of that theory to construct Treatment Plan (based on the ritual): case formulations from clinical data. 5. Negotiate treatment goals (ultimate outcomes) In this section I introduce a systematic method 6. Specify the revised personal characteristics (instrumental outcomes) for constructing case formulations that is not based 7. Select interventions upon any particular theory. This method is generic and it provides guidelines for translating any theory Figure 6. Steps in constructing case formulations and of psychotherapy into a case formulation. It is based treatment plans

Copyright  2003 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 10, 1–18 (2003) A Metamodel of Theories of Psychotherapy 13

disorganized behaviours (Rogers), as neurotic patient with a sociotropic personality becomes anxiety reactions and their secondary effects depressed whenever a latent, dysfunctional (Wolpe), or as maladaptive thoughts, feelings schema (e.g. ‘It is horrible to be rejected!’) is and behaviours (Beck). In general, the therapist activated by pertinent stressors like social rejec- uses the language of a favoured theory to char- tion (Clark et al., 1999). acterize the client’s cognitive, behavioural and (4) What are the origins of the dysfunctional affective difficulties. personality characteristics? In answering this, (2) What dysfunctional personal characteristics of the therapist speculates about the develop- the client are causing the client’s psychologi- ment of the personal characteristics posited to cal problems? In addressing this question, the underlie the client’s problems. This specula- therapist develops working hypotheses about tive account is an application of a favoured the idiosyncratic personal characteristics that theory’s myth to the life of the client. For are producing the client’s problems. This is the example, a cognitive therapist would describe heart of the case formulation. It is the ‘linch- a few incidents or circumstances of the pin’ or ‘causal/explanatory source’ (Bergner, client’s life (particularly episodes involving par- 1998), the ‘inferred mechanism’ (Eells et al., ents) that explain how the client might have 1998), the ‘hypothesized underlying mecha- learned maladaptive schemas. Most theories nism’ (Persons, 1989) that organizes the clinical provide an historical account of the develop- data of a case. To identify a client’s underlying ment of the client’s dysfunctional personality personal characteristics, therapists turn to the characteristics with an emphasis on incidents myths of their favoured theories. Each myth involving early caretakers. raises different questions. The Freudian analyst asks: What is the nature of this client’s unconscious conflicts? What are the unbearable TREATMENT PLANS AS ideas that this client is defending against and INSTANTIATIONS OF RITUALS that are being expressed in their symptoms? A treatment plan is an instantiation of a ritual, The Rogerian therapist asks: What particular just as a case formulation is an instantiation of aspects of this client’s experience are incon- a myth. Thus, treatment plans include the same gruent with the self and vice versa? What are components as rituals: (a) treatment goals (ulti- this client’s conditions of worth? The Wol- mate outcomes), (b) revised personal characteristics pean behaviour therapist asks: What are the (instrumental outcomes or treatment targets), and particular stimuli that elicit neurotic anxiety (c) interventions (cf. Persons & Tompkins, 1997). responses in this client? What are the neurotic As an instantiation of a ritual, a treatment plan is stimulus–response bonds? The cognitive ther- derived from an instantiation of a myth—the case apist asks: What are this client’s dysfunctional formulation. The treatment goals are derived from thoughts and schemas (beliefs about the self, the client’s problem list. In a treatment plan, the others, and the world)? In answering questions therapist outlines specific interventions to correct like these, the therapist ‘identifies the core state selected problems from the client’s problem list. of affairs from which all of the client’s difficul- The interventions target the dysfunctional personal ties issue’ (Bergner, 1998, p. 289). characteristics that are hypothesized to produce (3) How are the hypothesized personal character- the client’s psychological problems. The therapist istics causing the client’s psychological prob- selects particular interventions that the ritual pre- lems? In answering this question, the thera- scribes for revising these personal characteristics. pist describes the process whereby the client’s dysfunctional personal characteristics produce the problems on the problem list (cf. Per- CONTRIBUTIONS OF THE sons, 1989; Persons & Tompkins, 1997). The METAMODEL TO THE ANALYSIS, therapist draws upon the underlying psycho- COMPARISON, INTEGRATION, AND logical mechanisms of their favoured myths USE OF THEORIES to develop an account of this process. The The metamodel provides a fresh perspective for account may articulate how stressors activate understanding and using theories of psychother- personality characteristics (i.e. the diathesis) apy. The metamodel extends Frank’s (1982) con- to produce psychological problems. For exam- cepts of myth and ritual by articulating their struc- ple, a cognitive therapist might maintain that a ture. In doing so, the metamodel suggests a number

Copyright  2003 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 10, 1–18 (2003) 14 S. J. Morris of questions that help to organize thinking about the (reduction in the symptoms of emotional upsets myth and the ritual of a theory: how does the theory and self-defeating behaviours) with the revised construe psychological problems? What dysfunc- personal characteristic necessary to achieve this tional personality characteristics are presumed to goal (adoption of a rational philosophy). The meta- cause problems? What is the process whereby these model avoids this kind of confusion by providing personality characteristics cause problems? How a framework for distinguishing between the struc- do these personality characteristics come to be? tural components of theories. Turning to the ritual, how does the theory conceptualize treatment goals? How do the interventions promote revisions in the dysfunctional personal Comparing and Contrasting Theories of characteristics that lie at the root of psychological Psychotherapy problems? These questions uncover the underly- The metamodel provides a fresh framework for ing structure of a theory and capture its essential comparing and contrasting different theories as concepts and principles. Furthermore, these ques- well. Using the metamodel to analyse theories tions provide guidance in analysing, comparing, reveals the fundamental similarities and differ- and integrating theories and for constructing case ences in their basic concepts and principles. To formulations from them. In this section I consider illustrate, when using the metamodel to anal- how the metamodel provides a fresh framework yse psychoanalysis and person-centred therapy, for accomplishing each of these tasks. striking similarities and differences become abun- dantly clear. For example, it becomes clear that Analysing Theories of Psychotherapy in both theories symptoms reﬂect defences against ‘truths’ about the self that the client cannot face. The metamodel provides a framework for the In psychoanalysis, the truth involves a forbidden precise and rigorous analysis of theories of psy- wish; whereas in person-centred therapy, the truth chotherapy. The structural distinctions postulated involves an aspect of organismic experience that by the metamodel are not commonly made in the is incongruent with the self. To illustrate further, literature on psychotherapy. For example, con- a metamodel-based analysis can reveal distinct sider how Corey (2001) characterizes the goals theoretical explanations (i.e. hypothesized revised of person-centred therapy in his celebrated text- personal characteristics) for common intervention book: ‘To provide a safe climate conducive to strategies. For example, from the vantage point of clients’ self-exploration, so that they can recog- Wolpe’s behaviour therapy, exposure to a feared nize blocks to growth and can experience aspects object works by weakening the bond between a of self that were formerly denied or distorted. To conditioned stimulus and a conditioned anxiety enable them to move toward openness, greater trust response, whereas from the vantage point of cog- in self, willingness to be a process, and increased nitive therapy, exposure works by correcting an spontaneity and aliveness’ (p. 469). How can ‘to exaggerated perception of threat. provide a safe climate...’ be a treatment goal, an ultimate outcome, the reason for treatment? From the perspective of the metamodel, Corey’s Integrating Theories of Psychotherapy characterization confuses intervention (‘to provide a safe climate...’) and revised personal charac- The metamodel provides a fresh framework for teristics (‘...experience aspects of self that were psychotherapy integration. Reisman (1975) argued formerly denied or distorted’) with the actual treat- that training programmes ‘should provide a system ment goals (‘openness, greater trust in self...’). In of analysis or a framework by which a multiplicity fact, his characterization eloquently captures the of theories and methods could be organized into an entire ritual of person-centred therapy—not just the integrated understanding’ (p. 191). The metamodel treatment goals. This kind of confusing analysis offers such a framework, one that can be applied to abounds in discussions of theories of counselling each of the three main approaches to psychotherapy and psychotherapy. As Weiner (1975) observed, integration: theoretical integration, common factors some theorists confuse insight with a treatment goal and technical eclecticism (see Arkowitz, 1997). (ultimate outcome) rather than a means for achiev- ing a treatment goal (i.e. an instrumental outcome or Theoretical Integration revised personal characteristic). Similarly, as noted ‘The strongest emphasis in theoretical integra- earlier, Ellis (2000) confuses the goal of treatment tion is in integrating different components from

Copyright  2003 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 10, 1–18 (2003) A Metamodel of Theories of Psychotherapy 15 different approaches into a unified framework’ self and the world. Arguably, all forms of psy- (Arkowitz, 1997, p. 240). The most basic question chotherapy are directed at correcting clients’ basic about theoretical integration concerns the units misconceptions about themselves, their behaviour and forms of an integration (Arkowitz, 1997). Dif- and the world around them (Brady et al., 1980; ferent writers have proposed theory integration Corsini, 2000; Frank & Frank, 1991; Goldfried & at different levels or units of analysis, including Padawer, 1982; Raimy, 1975). In fact, most of the techniques, goals of change, theories, assumptions change processes identified as common factors by about human nature, and methods of verification Grencavage & Norcross (1990), are designed to (Arkowitz, 1997; Schacht, 1984). The ambiguity revise the client’s basic misconceptions (e.g. fos- about units and form has resulted in confusion ter insight, feedback/reality testing, persuasion, in the literature on theoretical integration (Schacht, success and mastery experiences). The metamodel 1984). The metamodel provides a template that extends Goldfried’s perspective on common factors clearly delineates the form and units of an integra- by offering a framework for thinking about them. tion. For example, the metamodel implies that an integration would combine the dysfunctional per- Technical Eclecticism sonal characteristics of different theories into a new Technical eclecticism ‘is the practice of selecting nomological network that accounts for psychologi- potentially effective procedures from different cal problems (i.e. a hybrid underlying psychological therapy orientations’ (Wolfe & Goldfried, 1988, mechanism). In general, the metamodel provides p. 448). In modern eclecticism, treatment selection is a framework for combining the components of based on ‘an actuarial approach that uses data from different theories into a coherent and internally past cases to predict what will work best for new consistent synthesis. cases’ (Arkowitz, 1997; p. 252). That is, treatments are selected on the basis of what has worked best for similar people with similar problems (Arkowitz, Common Factors 1997). The emphasis is on techniques. Theories The metamodel also provides a framework that and theoretical explanations are downplayed. This is useful to the common factors approach. This is a weakness of eclecticism (Arkowitz, 1989; approach ‘seeks common ingredients across ther- Eysenck, 1970). Eysenck (1970) derided eclecticism apies that account for their success’ (Westin, 2000, as ‘a mish-mash of theories, a hugger-mugger of p. 227). Interestingly, myths (provision of rationale) procedures, a gallimaufry of therapies’ (p. 145). and rituals themselves are among the most com- Arkowitz (1997) concluded that eclecticism requires monly cited common factors (Grencavage & Nor- greater theoretical structure. The metamodel offers cross, 1990). A major challenge facing this approach a minimal theoretical structure that fits the actuarial involves determining the type and level of common spirit of eclecticism. For example, it proposes that factors (Arkowitz, 1997). From the perspective of techniques should be linked to revised personal the metamodel, common factors can be viewed characteristics to provide a simple explanation of as revised personal characteristics (i.e. instrumen- what causes therapeutic change. tal outcomes). In a classic paper, Goldfried (1980) argued in favour of identifying commonalities at an intermediary level of abstraction, between broad Using Theories to Construct Case Formulations theories and specific techniques. He called this and Treatment Plans the level of clinical strategies or change principles. The metamodel provides guidance in building case Clinical strategies ‘consist of classes of therapeutic formulations and treatment plans from any theory activities that may all serve the same underlying of psychotherapy, thereby filling a void in the function’, for example ‘to achieve the common goal literature on the mechanics of case formulation. of helping clients/patients to shift their subjective Recent years have seen the development of a conceptions and view themselves and their world diversity of systematic methods for constructing more objectively’ (Goldfried, 1995, p. 223). From the case formulations, each from the perspective of perspective of the metamodel, the ‘common goal’ or a specific theory of psychotherapy (see Eells, the ‘underlying function’ of different methods is the 1997b). However, there remains little consensus revision of a dysfunctional personal characteristic. regarding the content, structure and goals of a That is, clinical strategies are classes of therapeu- case formulation and case formulation remains an tic activities that target a particular dysfunctional insufficiently taught and practiced skill (Eells et al., personal characteristic, like a distorted view of the 1998; Fleming & Patterson, 1993). Butler (1998)

Copyright  2003 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 10, 1–18 (2003) 16 S. J. Morris proposed that ‘This process (case formulation) rationale’ is widely assumed to be a common thera- might be facilitated if there was agreement over peutic component in the common factors literature which were the basic elements of a formulation (Grencavage & Norcross, 1990). and an atheoretical way of linking them together’ (p. 18). The metamodel-based approach provides just such a generic, atheoretical approach. The few available generic methods (Butler, 1998; Hansen & CONCLUSION Freimuth, 1997; McDougall & Reade, 1993; Meier, The metamodel delineates the underlying structure 1999; Murdock, 1991; Schwitzer, 1996; Weerasekera, shared by theories of psychotherapy. It is thereby 1993) do not adopt the premise that theories an aid in understanding theories—in analysing have the same structure as case formulations and, them, in comparing them and in integrating them. thus, do not make the case-formulation theory In addition, it is a guide to using theories to link as explicit. By linking the structure of case build case formulations and treatment plans out formulations and treatment plans to the structure of of clinical data. Finally, it provides guidance to theories, the metamodel-based approach provides practitioners in constructing their own personal a fresh perspective to the literature on case theories of psychotherapy. formulation. The metamodel-based method of case formulation is reminiscent of Persons’ method of cognitive- behavioural case formulation (Persons & Tompkins, ACKNOWLEDGEMENTS 1997; Persons, Davidson, & Tompkins, 2001), but hardly identical. The most unmistakable difference I am grateful to Nancy Cunningham, Pam King, is that the metamodel-based method is generic Anna Peterson, Eric Sleith, and Rebecca Harvey for whereas Person’s method is restricted to cognitive- their insightful comments on an earlier version of behaviour therapy. Although Persons’ analysis of this article. the theory of cognitive-behaviour therapy is com- patible with the structural analysis proposed by my metamodel (as it should be) and she implic- REFERENCES itly assumes that the structure of a cognitive- behavioural case formulation matches the structure of cognitive-behavioural theory, her model Addis, M.E., & Carpenter, K.M. (2000). The treatment is restricted to cognitive-behavioural therapy. She rationale in cognitive behavioral therapy: Psychological mechanisms and clinical guidelines. Cognitive and does not argue that her basic model can be gener- Behavioral Practice, 7, 147–156. alized to other theories nor does she suggest how Alford, B.A., & Beck, A.T. (1997). The integrative power of this might be accomplished. cognitive therapy. New York: Guilford. The metamodel provides a generic means for American Psychiatric Association. (2000). Diagnostic and bridging the gap between theory and practice. Not statistical manual of mental disorders (4th ed. TR). only is the metamodel useful in applying any the- Washington, DC: Author. Arlow, J.A. (2000). Psychoanalysis. In R.J. Corsini & ory to a particular case, but it is useful in developing D. Wedding (Eds), Current psychotherapies (6th ed.; one’s own personal theory of psychotherapy. It sug- pp. 16–53). Itasca, IL: F.E. Peacock. gests the questions the practitioner must address Arkowitz, H. (1989). The role of theory in psychotherapy in constructing a personal theory. With answers to integration. Journal of Integrative and Eclectic these questions, the practitioner develops a solid Psychotherapy, 8, 8–16. theoretical basis for case formulation and treat- Arkowitz, H. (1997). Integrative theories of psychotherapy. In P. Wachtel, & S.B. Messer (Eds), Theories of psy- ment planning. With answers to these questions, chotherapy: Origins and evolution (pp. 227–288). Wash- the practitioner is prepared to provide clients with a ington, DC: American Psychological Association. fresh and plausible view of their problems together Auld, F., & Hyman, M. (1991). Resolution of inner conﬂict: with a credible treatment rationale. According to An introduction to psychoanalytic therapy. Washington, a number of theorists (Addis & Carpenter, 2000; DC: American Psychological Association. Frank, 1982; Goldfried, 1980; Rosenzweig, 1936), Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory. Englewood Cliffs, NJ: Prentice getting clients to adopt a fresh outlook on their Hall. problems is an important ingredient in success- Beck, A.T. (1991). Cognitive therapy: A 30-year ful therapy. Indeed, ‘provision of a therapeutic retrospective. American Psychologist, 46, 368–375.

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