O’Donohue/Clinical Strategies for Becoming a Master Psychotherapist O’Dononhue_prelims Final Proof page xiii 16.2.2006 2:08am List of Contributors David Atkins (239), Fuller Graduate School of Psychology, Pasadena, CA 91182 Janet L. Cummings (iii, 1, 145, 309), The Nicholas & Dorothy Cummings Foundation, Scottsdale, AZ 85281 Nicholas A. Cummings (iii, 1, 129, 145, 291), University of Nevada Reno, Reno, NV 89503 Melanie P. Duckworth (71), University of Nevada Reno, Department of Psych- ology, Reno, NV 89557-0062 Michael Hoyt (113), Kaiser Permanente Medical Center, San Rafael, CA 94903 Tony Iezzi (71), London Health Sciences Centre, London, Ontario, Canada, N6A 4G5 Richard Kamins (189), Magellan Health Services, Public Sector Solutions, Greenwood Village, CO 21046 Eric, R. Levensky (11), University of Nevada, Reno, Department of Psychology, Reno, NV 89557-0062 Alvin R. Mahrer (167), University of Ottawa, Centre for Psychological Services, Ottawa, ON, K1N 6N5 Christopher R. Martell (239), Associates in Behavioral Health and University of Washington, Seattle, Washington 98122 Leigh McCullough (261), Harvard Medical School, Dedham, MA 02026 J. Christopher Muran (37), Beth Israel Medical Center, Albert Einstein College of Medicine, Department of Psychiatry and Behavioral Sciences New York, NY 10003 William T. O’Donohue (iii, 1, 209), University of Nevada Reno, Department of Psychology, Reno, NV 89557-0062 Clinical Strategies for Copyright ß 2005 by Elsevier. Becoming a Master Psychotherapist xiii All rights reserved. O’Donohue/Clinical Strategies for Becoming a Master Psychotherapist O’Dononhue_prelims Final Proof page xiv 16.2.2006 2:08am xiv List of Contributors Kristin A. R. Osborn (261), Psychotherapy Research Program, Harvard Medical School Department of Psychiatry, Cambridge, Massachusetts 02139 Lois J. Parker (55), University of Nevada Reno, Counseling and Career Services, Reno, NV 89557 Michael Rothman (37), Beth Israel Medical Center, Albert Einstein College of Medicine, Department of Psychiatry and Behavioral Sciences New York, NY 10003 Jeremy D. Safran (37), New School University, Department of Psychology, New York, NY 10003 Brett N. Steenbarger (277), Clinical Associate Professor of Psychiatry and Behavioral Sciences, SUNY Upstate Medical University, Syracuse, NY 13210 George Stricker (95), American School of Professional Psychology, Argosy University/Washington DC 22209 Jack Wetter (87), Diplomate and Fellow in Clinical Psychology, American Board of Professional Psychology, Los Angeles, California 90024 Michael G. Wetter (87), The Permanente Medical Group, Medical Office Build- ing, Union City, CA 94587 Paula L. Wilbourne (11), Center for Health Care Evaluation, VA Palo Alto Health Care System, Menlo Park, CA 94025 Jeffrey K. Zeig (223), Milton H. Erickson Foundation, Phoenix, AZ 85016 O’Donohue/Clinical Strategies for Becoming a Master Psychotherapist O’Dononhue_chap01 Final Proof page 1 16.12.2005 3:57am 1 The Art and Science of Psychotherapy William O’Donohue University of Nevada Reno, Nevada Nicholas Cummings University of Nevada Reno, Nevada Janet Cummings University of Nevada Reno, Nevada Psychotherapy is both an art and a science. Understanding the contribu- tion of both these elements and achieving a proper balance in actual episodes of therapy is essential to optimize therapeutic success. All too often, behav- ioral health professionals have emphasized one and neglected the other. A major mission of this book is to help redress this imbalance. We have produced other books that have focused on the scientific dimension of the psychotherapeutic enterprise (Cummings & Cummings, 2000; Fisher & O’Donohue, in press; O’Donohue, Fisher & Hayes, 2003). However, this scientific information is incomplete in regard to producing effective psycho- therapy. It is incomplete in two important ways. First, it does not cover key problems that if not resolved can impede progress, prematurely end therapy, or result in failure. These problems, if not recognized, confronted, and dealt with well can undermine therapy, even if the therapist is using an empirically supported treatment manual. Moreover, unfortunately, these problems are not rare. Examples of these problems include building a therapeutic rela- tionship, handling resistance, constructing a case formulation, and, on the other end of the therapy time line, terminating appropriately. Second, this Clinical Strategies for Copyright ß 2006 by Elsevier. Becoming a Master Psychotherapist 1 All rights reserved. O’Donohue/Clinical Strategies for Becoming a Master Psychotherapist O’Dononhue_chap01 Final Proof page 2 16.12.2005 3:57am 2 Clinical Strategies for Becoming a Master Psychotherapist scientific information often does not fully cover the ‘‘art’’ or ‘‘craft’’ of implementing these evidence-based techniques, (i.e., the nuances, the cre- ative maneuvers, the dexterity, the problem-solving strategies when difficul- ties arise). This book is an attempt to have high-profile, expert ‘‘master’’ therapists discuss the craft of handling these key issues. Let’s examine two examples. The research clearly shows nonspecific factors such as the therapeutic alliance that accounts for a lot of variance in therapy outcome (Thomas, Werner–Wilson & Murphy, 2005). However, this literature is weak in describing the art of establishing and maintaining these nonspecific factors. Thus, a key task in therapy is creating and main- taining an optimal therapeutic relationship. Beginning therapists might mistakenly think that what is involved is simply ‘‘being nice.’’ Clearly, this is not it at all. The therapeutic relationship certainly has to involve elements such as empathy, positive regard, and instilling hope —and these can feel somewhat ‘‘nice’’ to the client, but the relationship also must involve per- sistence in moving the client to explore areas they do not want to; giving honest, useful but perhaps unwanted feedback; drawing clear boundaries (particularly with certain clients such as those with borderline personality disorder); tough love; and so forth Thus, this book contains a chapter by a leading clinical authority, Dr. Jeremy Safran, that describes the art of establishing and maintaining a therapeutic relationship. Our second example: Although many empirically supported treatment manuals assume clients will always cooperate, do homework, tell us accurate and complete information, clinicians know of the many ways clients dem- onstrate resistance in psychotherapy. Thus, we have also included a chapter by one of the co-editors, Dr. Nicholas Cummings, on understanding and dealing with resistance. PSYCHOTHERAPY IS NOT ENTIRELY AN ART However, another all too common mistake is to view psychotherapy as entirely an art. In this view, each psychotherapist with each client is engaged is some sort of creative enterprise bounded only by the artist’s choices among many possible paths in which spontaneous reactions of the artist/ psychotherapist are causally related to improvements in the client. In this view, there may be some commonalities (as art can be grouped into schools such as impressionism, Dadaism, cubism, and so on.) so that, although therapeutic styles may be at times grouped into ‘‘schools,’’ each artist/ psychotherapist is essentially unique. Improvisational jazz is perhaps the best metaphor here. Sometimes, the art argument is based on the uniqueness of each human (applying to both the client and the therapist) and the uniqueness of their problems, thus attempting to justify a radically unique O’Donohue/Clinical Strategies for Becoming a Master Psychotherapist O’Dononhue_chap01 Final Proof page 3 16.12.2005 3:57am 1. The Art and Science of Psychotherapy 3 approach to each case. At other times, the argument can be based on the uniqueness of the moment—that each therapist and each client in each moment of psychotherapy is sui generis and thus only a corresponding unique response to this can be therapeutic. According to this view, there are few or no general laws then, because this uniqueness defies generalization over common types. We believe there are three major problems with this view. First, there is the causal problem. In health care we know (painfully so) that not all events lead to the healing effects we want. Not all salves stop poison ivy from itching. Not all treatments stop a cancerous tumor. Not all speech acts stop a suicidal individual. And not all interventions will decrease a patient’s belief in a delusion. Some events will have a positive impact on these; many will not. To think that a therapist can simply spontaneously improvise and consistently instantiate one of these ameliorative causal factors is either overly optimistic or, when talking about the self, narcissistic in the extreme. A related problem is that even if a particular therapist–artist is wonderful, there is a scalability problem. Is this therapist talented for all patients with all kinds of problems? If this therapist is an excellent artist, it would seem to have very little to do with other therapists and their clients. The second major problem is that, in most arts, the majority of so called ‘‘artists’’ are not all that good. In fact, most are pretty bad. For every Picasso or Rembrandt or Modigliani, there are thousands of untalented ‘‘starving artists’’ who are reaping the just economic rewards of their talent. Thus, the problem becomes, if psychotherapy is an art, how we can justify the Lake Woebegone claim that ‘‘all the artists are above average’’ and all deserve prizes? The final problem is that psychotherapy