What Works with Individuals in a Clinical Setting?

Castelnuovo’s review of research on psychotherapeutical effectiveness (Castelnuovo, 2010), gathers together and summarizes a large body of literature. It explains the background of methods used in psychotherapeutic outcome research, while examining the premises behind the empirically supported treatment (EST) movement, clearly demonstrating the truth of Wittgenstein’s sentence: “Tell me how you do research and I will say what you research” (Wittgenstein, 1921, p. 13). It is not the object of research that determines the methodology chosen; on the contrary, it is the implicit investigation criteria that define (and selectively construct) the object of research. The assessment of effectiveness goes to the heart of the problem of how the research plan influences the result of any comparison between different approaches: the closer the treatment gets to the chosen methodology, the more probability it has to obtain positive results. The method chosen contributes to establishing the nature of the problem to which it is applied, and when the method is based on the classic empirical tradition, the psychological problems which it investigates logically appear to occur naturally, in the end (Castelnuovo et al., 2004, 2005). Westen et al. (2004) remind us that the way in which we ultimately decide upon the experimental method involves another series of assumptions; i.e., that the experimental method represents the Gold Standard for identifying truly efficacious treatment plans; that psychotherapy lends itself to a high degree of manipulation; that a large number of patients presenting the same problem can be treated at the same time (which in turn presumes that psychotherapy can effectively treat everyone). Therefore, only certain theoretical and clinical approaches are well represented by outcome-focused research: those approaches aiming to make the symptom disappear, being inspired, as they are, by the “medical model” (Elkins, 2009). According to estimates (Truscott, 2010), there are around 250 different theories and approaches. In order to be considered epistemologically valid, any approach must define its effectiveness coherently with its assumptions. An approach must be proven on the same level on which it declaredly operates: a behavioral level for behavioral therapy, a language level for a narrative approach, etc. The increasing focus on treatment goals often neglects the need for more effective differentiation within psychotherapeutic approaches, in light of the persisting equivalence paradox (Strauss, 2010). Any attempt to provide a single, overall conceptualization of effectiveness in psychotherapy is destined to suffer from partiality and reductivism: any definition is necessarily linked to the epistemological background which has generated it (“we must measure the correlation between what an approach promises and its final outcome, independently of the approach chosen” Castelnuovo, 2010, p. 8). If we consider the history of EST movement, we see that researchers initially tended to welcome the methodology used for random and controlled trials, mainly because of its inherent potential. Later, however, many researchers have moved on from unconditional trust in the experimental method to cautious skepticism: paradoxically, the more rigorous and provable research is according to criteria linked to “classic scientific method,” the less it becomes valid, significant and classifiable from the point of view of day-to-day practice. For this reason, representing psychotherapeutical processes and applying research findings and recommendations to the therapeutic field continue to prove difficult. As Castelnuovo points out, research into psychotherapy should enhance the experience of both therapist and client. For this to occur, quantitative and qualitative data, or objective and subjective experiences, “should collude rather than collide” (Campbell, 2008, p. 47). We must couple the effort to find statistically significant measurements with the equally important effort to discover clinical significance. Both the quantitative and the qualitative methodology, though differing greatly, are indispensable in overcoming any difficulty deriving from an overestimation of the subjective or objective level (Campbell, 2008). To conclude, as Hagemoser (2009, p. 601) lucidly observes, although the proponents of empirically supported therapies (ESTs) argue that “because manualized ESTs have demonstrated efficacy in treating a range of psychological disorders, they should be the treatments of choice,” their success does not derive from their assumptions, which are full of gaps and logically weak; but instead, from economical and political variables which may be contributing to the expansion of ESTs, and to a resulting restriction of the practitioner’s autonomy.