Psychotherapy Research 8(2) 141-157, 1998

EMPIRICALLY VIOLATED TREATMENTS: DISENFRANCHISEMENT OF HUMANISTIC AND OTHER PSYCHOTHERAPIES

Arthur C. Bohart
California State University Dominguez Hills

Maureen OHara
Saybrook Graduate School

Larry M. Leitner
Miami University (Ohio)
It is argued that the criteria for empiricallyvalidated treatments are restrictive and scientificallyunjustified, could disenfranchisetherapies which do not share the Division 12 task forces assumptions about the nature of psychotherapy, and will stifle psychological research. The criteria are based on a medical-like meta-model of psychotherapy designed to appeal to the managed-care market, but are inappropriate for therapies whose primary focus is not to cure disorder. We argue that empirical support for a therapy should include research based on methods compatible with the assumptions of the therapy, in particular on what it means to say that a given therapy works.Neither manualization nor the requirement of targeting therapy for treating specific disorders necessarily fit with humanistic assumptions. Natural science methodology also should not be privileged over human science methodology. Under criteria other than those of the task force there is considerable empirical support for humanistic assumptions.

Humanistic therapies, as well as others which share some similar assumptions, such as some constructivistic, feminist, and strategic therapies, are threatened with disenfranchisement by the arbitrary and restrictive guidelines for deciding what is an empirically validated treatment developed by a task force of Division 12 of the American Psychological Association (1995). By putting out a list of empirically validated treatments and by implying that therapies that do not meet the criteria are either experimental or not empirically validated, the guidelines may expose persons practicing from alternative theories to the possibility of malpractice suits. Graduate schools may face requirements to alter criteria in favor of the empirically validated treatments. The development of these criteria has been particularly unfortunate because, despite its claims for methodological superiority, the driving force behind the task
The authors would like to thank David Rennie, Ph.D., as well as the anonymous reviewers for their help in developing this article. Correspondence concerning this article should be addressed to Arthur C. Bohart, Ph.D., Department of Psychology, California State University Dominguez Hills, Carson, CA 90747

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forces project is so obviously financial and territorial. The opening paragraphs of its report reveal its desire to appeal to the interests of the managed-care industry and its conviction that psychology needs to compete for power with biological psychiatry. The evaluation criteria chosen are ones that make psychological treatment more palatable to managed-care companies and to the government, both of which conceptualize treatment in medical-like terms. Our first issue is with the very concept of empirical validation. We second a recent acknowledgment by the task force itself (Chambless et al., 1996) that empirical investigation can only lead to empirical support for a therapy, but never to validation. If a therapy can never be fully validated, but only supported, then it is meaningless to set restrictive criteria for when a therapy has achieved a status of supported because there are varying levels of support, and varying kinds of evidence. Empirical support would logically not be restricted to global outcome studies, but would include evidence for various subprocesses and mini-outcomes (Greenberg, 1986) postulated by the therapy, such as transference interpretations can facilitate insight, or the empty chair procedure helps people move to deeper levels of experiencing and resolve unfinished business with significant others. Yet these kinds of findings are totally neglected in the task forces criteria, leading to a distorted picture of how much empirical support there is for a variety of therapeutic approaches. At heart, empirical investigation of psychotherapy should have two interlocking goals. The first is the issue of accountability: Does the therapy work-meaning, does it deliver what it promises?The second has to do with the furthering of psychological science: Does investigation illuminate our understanding o f human change? For any given therapy there are many different answers to the question of whether it works or not-works for what? For instance, a therapy could be said to work in the sense that it helped people change their dysfunctional cognitions, helped them learn about their pasts, or helped them grow. Humanistic therapies are generally not meant to be specific treatments for disorders. Therefore, showing empirical support for them would be to demonstrate that they work in the way they say they work. This might include showing that a humanistic therapist provides a kind of growthproducing climate where clients have the opportunity to examinehnvestigate their lives, or that dialogue with a deeply respectful and empathic human being provides the opportunity for deep experiencing and personal meaning-making. However the task force has defined work(empiricallyvalidated) only in one delimited way as cure disorder or alleviate a predefined problem. This is based on a simplistic analogy to medicine and use of the drug metaphor (Stiles & Shapiro, 1989). In brief, the task force argues that in order for a therapy to be empirically validated it must be studied as a treatment for a disorder or problem, be manualized, and be validated either by two different studies done using a randomized clinicaltrials design, or by use of a single-subject design (traditionally of relevance primarily to behavioral therapies). It makes a strong argument for the necessity of manualization, stressing the specificity achieved, as well as manualizations use for the adequate training of therapists. It says, Such standardization and precise definition of treatment through treatment manuals reduces the methodological problems caused by variable therapist outcomes and leads to more specific clinical recommendations. (Task Force, 1995, p. 4). It also argues that we believe no treatment will work for all problems, and it is essential to verify which treatments work for which types of problems (p. 4). It thus requires that researchers clearly specify characteristics of the client sample. The task force does not specify what this means, but it is clear that

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they mean that the sample must be specified in terms of the problem or disorder being treated. Based on these criteria the task force then dismisses conclusions of years of psychotherapy efficacy research because (a) the research was done prior to the establishment of a reliable categorization of clinical disorders-DSM 111, and (b) it was done prior to the use of treatment manuals to standardize practice. In so doing, it also concludes that the dodo bird verdict that all therapies work equally well can now be dismissed. Our roadmap for this paper is as follows. First we identify the underlying medical-like meta-model of psychotherapy practice implied by the task forces criteria. Then we distinguish this model from key elements of many forms of humanistic practice. Then we show how two aspects of the task forcescriteria discriminate against these forms of humanistic practice: manualization, and the requirement for some kind of diagnosis or classification of client problem. We follow this with a consideration of fundamental philosophy o f science issues-the implied natural-science paradigm favored by the task force versus the human-science paradigm favored by many humanistic scientists. We follow this with a critique of how the task forces criteria have already made legitimate humanistic research disappear. Next we present an example of an alternative-how to evaluate a humanistic therapy in its own terms. We conclude with a brief discussion of some of the negative consequences for humanistic therapies were the task forces criteria to reign supreme, and a consideration of implications of our argument for the interface of humanistic psychotherapy and managed care. A framing assumption of our argument is that different approaches to psychotherapy are analogous to scientific paradigms (Kuhn, 1970). They are internally coherent packages of assumptions about the nature of human beings, change, and psychotherapy practice. These assumptions dictate what will be appropriate empirical questions and the methods for empirically investigating the practice. Therapies should be empirically studied in terms that are appropriate to the framing assumptions of the paradigm.The criteria laid down by the task force are out of paradigm for various humanistic (and other) approaches.

TWO OPPOSING GENERAL MODELS OF PSYCHOTHERAPY

MEDICAL-LIKE META-MODEL OF PSYCHOTHERAPY The task forces criteria are based on a medical-like meta-model of therapy (e.g., Orlinsky, 1989). In medicine the physician diagnoses the patients disorder and then applies a treatment to it. The disorder is viewed as a well-defined entity, and the treatment is a relatively invariant package which is applied to the disorder and remedies it. Validation of the treatment means demonstrating that the treatment is the efficient cause of the alleviation of the disorder. Stiles and Shapiro (1989) have referred to this model when applied to psychotherapy as the drug metaphor. In order to research this, one must specify the treatment and make sure it is being applied correctly (or one cannot say it is the treatment that makes the difference) and one must specify the condition to be alleviated (or one cannot say that the treatment works for this condition). Under this rubric, the task forces requirement of manualization (to specify the treatment) and diagnosis (in some form) of the patient population, makes sense. This

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is also a differential-treatment model in that it is assumed that, analogous to medicine, differential treatments can be found and applied to different client disorders. Randomized clinical trials, as in medicine, become the ideal empirical strategy. The goal is to demonstrate a clear-cut linear efficient-causal relationship between application of the treatment and alleviation of the disorder. While the logic of this model seems impeccable, there are assumptions hidden in it: (a) it is the treatment that does the work (i.e., cures the disorder) and not the individual therapist or relationship, and (b) all those sharing the same disorder can be treated similarly. In general, psychotherapy is seen as a relatively straightforward linear-causal affair where (a) a problem is specified in advance, (b) a treatment is chosen for the problem, and (c) a therapist expertly applies the treatment to the problem. While treatments may not actually be medical-like (many therapies are educational), they are still thought of analogous to medical treatment (Orlinsky, 1989). The very term treatment is part o f the medical legacy of psychotherapys origins (Szasz, 1998). Therefore, medical-like thinking remains the dominant underlying influence in framing how our field thinks about psychotherapy, and is embedded in the task forces criteria. HUMANISTIC, GROWTH-ORIENTED, AND MEANING-MAKING MODELS Humanistic therapists do not speak with one voice, but most hold beliefs that do not fit with the above model. Leitner (1994) views therapy as the application of theory to distress, i.e., as the use of theory to help understand distress-a definition incompatible with a medicalized view. Others do not see themselves as treating problems at all. Carl Rogers noted that in most real moments of therapy he was not motivated to help, but rather to meet the other person. Ive learned through my experience that when we can meet, then help does occur, but thats a by-product (Rogers, as quoted in Cissna & Anderson, 1994, p. 28). In this section we present a general humanistic model which differs sharply from the medical-like model. While this model does not represent the views of all humanists, it illustrates the problems in the Task Forces criteria. General humanistic model. First, psychotherapy is not disorder-driven.The goal is not to alleviate a disorder, nor cure a condition, nor even to solve a problem. The goal is to provide a relationship as an optimal context within which an active, agentic client can reflect upon the patterns of his or her life. The therapist interacts with the client and through that interaction provides the client with an opportunity to experientially explore, examine, reflect, have a creative, co-constructive interactive experience with the therapist, and through all this, reevaluate whatever life choices the person has made/is making, and revise if necessary. This may be motivated by the clients experience of distress, and one goal of the therapy may ultimately be to help the client alleviate the distress. But the focus of the therapy is not the distress, as if the distress were a pathogento be removed, or a conditionto be diagnosed and treated.Rather, distress is seen as secondary to the individuals pursuing a more satisfying, meaningful life, and that is the primary focus of the therapy. There is thus no a priori reason why anyone could not avail themselves of such a relationship, regardless of their diagnosis. All people experience, value, set goals, make choices, evaluate, reflect, and are therefore potentially capable o f utilizing the kind of experience a humanistic therapist provides. Even if a client had entered therapy with an explicit presenting problem, in such a context there would be no guarantee

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that the presenting problem would become the focus of the meaning-making activities. The context is one in which clients make new meaning, and they might decide to work on things other than their presenting problem, to focus on future goals and personal development, to use the context to test out new relational skills, or to simply have a place to relax and think (Bohart & Tallman, 1996). Successful therapy may be totally independent of symptom reduction. What is promised by the humanistic therapist is that a certain type of context and relationship will be provided which f ones life. promotes exploration, reflection, and recharting o Second, rather than the application o f a predesigned treatmentto a previously identified problem,therapy is an open-ended process of discovery and meaningmaking. Outcome is often an emergent product of the process (Kampis, 1991), not connected to it in any clear linear efficient causal fashion. The therapist is a disciplined improvisational artist, not a manual-driven technician. Therapy consists of engaging in an ongoing co-constructive dialogue with the client. As the dialogue progresses, specific techiques may emerge as relevant at given points, but these cannot be specified or anticipated in advance. The important skills of the therapist are the ability to (a) empathically enter the world of the client and engage in a genuine meeting o f persons, (b) engage in co-constructive dialogue, and (c) be exquisitely sensitive to whats happening nowand to the potential for productive interaction and emergent new directions in each moment. In this model differentialtherapeutics consists of exquisitely sensitive differential responding in the moment (see Stiles, Shapiro, and Barkhams concept of responsive versus ballistic matching; Norcross et al., 1993). Third, the therapist is the treatment of choice, not the therapy, nor any treatment package. A therapists particular theoretical stance and package of techniques are ways to implement his or her therapeutic interpersonal presence and spontaneity, rather than specific things done to make therapy happen. Different therapists can practice in widely different ways, use widely different techniques at given choice points, and still be effective if they are implementing certain fundamental humanistic principles. Thus, uniformity of therapist behavior is neither expected nor desired. What is desirable is that therapists individually be themselves in their own idiosyncratic healing ways. Therapists will not necessarily even be consistent from one moment to the next, as they flexibly adjust to the emerging flow of interaction between themselves and the client. Fourth, diagnosis is not the preset identification of some category that the individual falls within, which is then to be modified by treatment. Many humanists are especially critical of DSM-IV, with its dehumanized view of psychological problems (Faidley & Leitner, 1993). Rather, diagnoses are interactionallydecided upon by therapist and client together, if they are used at all, and are inherently not fixed. Fifth, the therapist adheres to certain general humanistic principles. These include: (a) discovery: therapy is primarily a creative, meaning-making activity, with no specific predefined outcome or solution; (b) client agency: it is the client who is ultimately the expert and who decides what changes to make and how to make them; (c) respecting the personal reality of the client, and of seeing the client as an authentic source of experience; (d) adopting, fortethical and philosophical reasons as well as therapeutic ones, a democratic, egalitarian stance vis-2-vis the client; (el having a commitment to empathicallyunderstanding the clientsframe of reference; and (0 respectfully being authentic with the client. In such a model, it is proscribed to go in with a predefined f the client in disorderlike terms treatment plan based on client problems or to think o as this gets in the way of tuning into client individuality, strength, and potential.

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This simply is not a medical-like treatment model. Nothing is being applied to anyone. In contrast to therapy as the mechanical application of a treatment procedure, therapy is a recursive, self-adjusting, creative, interactive intelligent process (Karen Tallman, personal communication, October 19961, a complex nonlinear dynamic system. The two major variables in this approach are therapist and client, not treatment and disorder, and dialogue is its sine qua non. Theoretical ideas, techniques, etc., are adjuncts to the therapists listening-interacting process and take on their meaning contextually (Butler & Strupp, 1986). There is no such thing as an invariant procedure being applied to someone. Thus it is philosophically meaningless from this perspective to compare procedures to no procedures (treatment-control) or procedure set A to procedure set B (comparative treatments). One might be able to do it, and get some results, but one is not truly investigating the therapy as it is really practiced. As such, simple linear research models which might be appropriate for the study of the use of a medication do not do justice to understanding the complexity of this kind of psychotherapeutic interaction.

WHY THE TASK FORCE CRITERIA ARE INAPPROPRIATE FOR HUMANISTIC THERAPY

MANUALIZATION The task force makes two requirements for manualization as a condition for therapy research that the manual (a) describes how the procedures are to be used to treat a particular problem or disorder and (b) specifies the procedures. However, in the humanistic model, therapies are not treatments for disorders. Rather than focusing on a clients depression the therapist tries to provide a growth producing climate within which a client can make evaluations of life. Therapy could proceed entirely without depression ever being talked about (although this is unlikely) and without anything specifically being done to treatthe depression. Therefore, manualization for a disorder or a problem is theoretically meaningless. Manualizing in terms of specific procedures is equally meaningless. The concept of manualizationtypically implies a relatively specific set of rules and procedures which tell people in a given domain how to behave and what to do if. The publication manual of the American Psychological Association is a good example. It is clear from the task forces comments on specificity, precision, and standardization, that this is what they mean by manualization. However, for humanistic therapy a flexible spontaneous responding in the moment is valued. In our model creative improvisation is the key and therapist variation is desirable. Therapy cannot be precisely specified. A humanistic therapist generally adheres to certain philosophies of humans and of helpful interactions that cannot be operationalized in specific identifiable therapist behaviors or speech acts. For instance, while Carl Rogers style was consistent and identifiable, client-centered theory emphasizes generalized attitudes (unconditional positive regard, empathy, congruence), and these can be manifested in many different behaviors that are situationally appropriate at different times (OHara, 1997). In fact, client-centered therapists practice in widely different ways (Hart, 1970), and Rogers himself approved of this diversity. Therefore, in the typical meaning of a manual, neither client-centered therapy nor our general humanistic therapy can meaningfully be manualized.

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Yet the task force assumes that all therapies can be manualized. At one level of generality, this is true. A manual could be written at a high level of abstraction. It would include statements like therapist is to respond creatively in the moment, and therapist is to engage in co-constructive dialogue. However, if a manual can be written at such an abstract level then we have already written it above when we specified our principles. Further, all humanistic therapies, indeed all therapies in general, have already been manualized, since books have been written describing their general principles. The task force mentions a manual on client-centered therapy written by Rice (unpublished). However this is a general statement of client-centered principles in little more detail than one could glean from Rogers writings. We believe that writing a manual at such a high level of abstraction is an exercise in form rather than in substance. Writing a more specific manual would distort the practice, and foreclose on meaningful psychological research. Ultimately, even if it were possible to manualize humanistic therapies for the treatment of specific disorders, to do so mns against important assumptions o f many humanistic approaches. Therapists following manuals would not be truly practicing in humanistic ways. This raises the question of why would we want to?It is much better to not manualize, let the practice live in its natural habitat, and to study it, than to distort it in an a priori fashion. It would be like prematurely forcing improvisational jazz musicians to manualize their playing in order to study jazz. Finally, humanists believe that therapy is a genuine meeting of persons, and this cannot meaningfully be manualized (Leitner, 1994). An alternative to manualization is to measure adherence. Can it be said that therapists are adhering to the general philosophies and principles of the approach? We believe measuring therapists adherence to general humanistic principles is meaningful and useful. Adherence could be measured through either client or expert ratings (or both) of the degree to which the therapy process has lived up to the principles presented above. One argument raised by the task force for manualization is that if therapy is not manualized how can it be taught? However, there are many things that are teachable (primarily through interactive facilitation and example) that are not manualizable in any specific procedural sense. Creative artists facilitate the development of students idiosyncratic talents without teaching them to follow a manual. Good parents teach children how to love without giving them love manuals, and so on. Sex therapists may use manuals (e.g., how to books and films) to increase clientsknowledge about sex, but no sex therapist we know of encourages manualizedpractice when making love. Instead, clients are encouraged ultimately to be spontaneous and bethemselves. However, even if one could manualize the teaching of a humanistic therapy, this would not be the same as a manual for thepractice of that therapy. For instance, one might develop a teaching manual full of exercises to facilitate development of empathy, genuineness,and creativity. These exercises (perhaps practice role-playing clients) would have no direct, prescriptive connection with how the therapist spontaneously embodies these qualities in therapy. Thus one could teach the therapy without manualizing the practice, which would by definition be idiosyncratic. It is true that some humanistic therapies have been manualized (e.g., Greenberg, Rice, & Elliott, 1993; Mahrer, 1989). However, Mahrers experiential therapy manual is not, nor can it ever be (for theoretical reasons) a treatment manual for a particular problem or disorder (Mahrer, personal communication,August, 1996). The Greenberg et al. manual is prescriptive and systematic precisely in a way that is rejected by some humanists (particularly traditional client-centered therapists).

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A number of others have raised criticisms relevant to our objections to manualization. Rosenbaum (1994) says, Therapy requires a constant, ongoing process where the therapist adjusts to the client, and the client adjusts to this adjustment. This makes the manualizing of therapy precisely the wrong strategy for psychotherapy research: it attempts to mandate a process that to be successful, must proceed with a good deal of spontaneity, in its own fashion. (pp. 248-249). Ryle (1995) argues . . . no amount of therapist training or manualization can alter the fact that each therapeutic encounter involves two people who create different processes and that these differences are of significance (p. 114). Stiles, Shapiro, and Barkham (Norcross et al., 1993) note The drug metaphor is misleading in overlooking the intricate mutual responsiveness of therapist and client (p. 98). Strupp and Anderson (1997) argue that many important helpful aspects of therapy cannot be manualized, particularly those that involve the relationship. In addition, some evidence suggests manualization might be therapeutically counterproductive. With psychodynamic therapy it actually can lead to deterioration in certain aspects of therapists interpersonal skills (Binder, 1993). Further, manualization seems to be better at teaching a kind of mechanistic adherence to the procedures of the therapy rather than skillful, flexible application (Binder, 1993; Binder, Strupp, Bongar, Lee, Messer, & Peake, 1993). These effects would be particularly devastating to a humanistic therapist, whose stock in trade is the ability to establish a therapeutic relationship, and to skillfully improvise in the moment. This is not the place to criticize manuals in general, but the above points lead us to wonder if manualization is meaningful for any approach to therapy. Personally, we have seen-and used-manuals by Beck (Beck, Rush, Shaw, & Emery, 19791, Luborsky (19841, and Greenberg et al. (19931, among others. We do not believe that any of these manuals by themselves, without rigorous experiential practice and training under the guidance of experts in the approach, can really guide practice. It is important to note that in research studies the therapists have been so rigorously trained, and then their practice carefully monitored by the researchers (Dobson & Shaw, 19931, leading to the illusion that it is the manual that is responsible for the uniformity in therapist behavior, when in fact it is far more likely that it is the rigorous training, practice, and monitoring.

THE REQUIREMENT OF STUDYING POPULATIONS DEFINED BY DISORDER OR PROBLEM The task force requires careful specification of the population receiving the therapy. However, this is so vague that it does not rule out any previous psychotherapy research, where populations were at least carefully specified on some dimensions, if only that they were all neurotics.What the task force appears to really mean is that the population must be carefully specified in terms of the kind of problem or disorder which the therapy is presumed to be treating. However, the requirement of specifying the population in terms of a disorder to be treated is only one of many possible dimensions which could be studied for research purposes. It is not a particularly relevant one for many humanistic therapies (beyond, perhaps, the specification of neurotic which was done in early clientcentered studies to differentiate from psychotic).Because therapists are focusing on client potential, there is no a priori reason to specify, identify, or diagnose problems or disorders. The problem with requiring our humanistic model to be studied by applying it to a group of individuals with a common disorder or problem is that

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(a) it forces the practitioner or researcher to focus on a dimension that they would not naturally focus on: client disorder; (b) it implies that the goal of the therapy is to allieviate the disorder; and (c) it focuses on the wrong end of the horse in trying to understand the nature of the therapy, because the therapy is simply not disorderdriven. However, one could study our humanistic therapy with specific disorders (and in fact client-centered therapy has been so studied). Thus it could be empirically supported in terms of the task force criteria. However, because this is not the primary job that our,humanistic therapy is designed to do, criteria for empirical support must not be limited to the kinds demanded by the task force. To do so becomes a kind of philosophical imperialism. RANDOMIZED CLINICAL TRIALS AND HUMAN SCIENCE
At a more basic level, underlying the Task Forces requirements of manualization and specification of disorder, lies its privileging of a particular form of natural science methodology as the ultimate validational criterion for psychotherapy-that of the randomized controlled clinical trial (RCT). Yet even those who adhere to natural science methods do not necessarily see RCTs as optimal for studying psychotherapy (e.g., Greenberg, 1991). Human science methods (e.g, Rennie, 1994, 1996; Wertz, 1995) are accorded secondary status and marginalized by the task forces criteria. Yet we believe human science methods may be at least as valid for the study of humanistic psychotherapies (and indeed psychotherapy in general) as natural science methods. Many psychotherapies are complex nonlinear interactive processes (Greenberg, 1991). Treatmentsare continually being co-created and modified in an inductive, discovery-oriented fashion, by therapists and clients together. The best ways of studying such complex, nonformal phenomena are often qualitative and frequently involve dialogue with the subjects themselves. Human science methodologies, evolving out of an alternative theoretical view of psychology as praxis (Faidley & Leitner, 1993), have stands toward validity and reliability of knowledge that, while equally rigorous, are incompatible with traditional natural science philosophies. In contrast to natural-science methodology, human-science researchers focus on examination of personal experience and subjectivity.Most such researchers view their goal as the attainment of an understanding of the phenonemon of interest, and put forward that understanding as plausible (Rennie, 1994; 1996).Within this general framework some qualitative methodologists such as Rennie (1994, 1996) stress that understanding inevitably involves interpretation. Others, such as Wertz (1995) hold that understanding can be attained through concrete, descriptive elucidation. In either case, the logic of these methodologies is different from that of the formal, hypotheticodeductive experimentalgroup design which the task force favors. For instance, to quote Wertz (1995), Fidelityto what humans live through is the criterion for scientific adequacy of knowledge statements, and careful descriptive understanding is the basis of plausibility assessment(p. 295). Wertz points out that Toulmin and Leary (19941, in a recent critique, consider the overemphasis on the experimental method, the cornerstone o f the task forces criteria, as a cultof empiricism. He further notes (p. 299) that It is truly ironic that . . . the cult of empiricism, denounced by historians, philosophers, a vast plurality of contemporary psychologists, and even physical scientists themselves would be endorsed by the task force. Wertz notes that data from other methods are marginalized or left out altogether. Wertz suggests, as do we, that this is driven by market demands rather than by truly scientific considerations.

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Nonetheless we do not wish to take a stand against natural-science methodology. For one thing, despite the apparent mismatch between the inductive, openended discovery-oriented process that is humanistic therapy and the natural-science hypothetico-deductive method, natural-science methods have frequently been used to study humanistic psychotherapy (Carl Rogers was the first example of this, although late in his life he came to advocate qualitative methods). For another thing, we do not wish to fall into the trap of advocating methodological hegemony as has the task force. While we individually believe that human science and discoveryoriented (Greenberg, 1991) research methods are more compatible with humanistic therapy than is the randomized clinical trial, we believe it best if the field stay methodologically open. What is more important is that one methodology not be privileged over others. A number of human-science studies of psychotherapy have been conducted (e.g., Journal ofcounseling Psychology, 1994). Most are studies of psychotherapy process, or of in-session mini-outcomes (e.g., Rennie, 1990; Watson & Rennie, 1994), although for human science research the distinction between. process and outcome diminishes in importance. Studies focusing on outcome from a human-science perspective would emphasize comparisons and contrasts among individualized change trajectories (e.g., Cummings, Hallberg, & Slemon, 1994), rather than RCTs. In-depth interviews with clients would be used for outcome assessment, along with interpretive analyses of change trajectories over therapy sessions. It is not the place here to go into detail on how human-science practitioners make meaning out of such data. Suffice it to say that interpretive assessments of causality and other forms of explanation (e.g., intention) would be established utilizing the various methods humanscience practitioners use for establishing the plausibility of such interpretations (Rennie, 1994; Faidley & Leitner, 1993). UNDER ALTERNATIVE CRITERIA, HUMANISTIC THERAPIES HAVE ALREADY BEEN EMPIRICALLY SUPPORTED It is on the basis of the criteria of manualization and specification of disorder that the task force is able to ignore a substantial amount of both natural- and humanscience research that supports humanistic therapies. Consider client-centered therapy in particular. The goal of Rogerian therapy is not to relieve a disorder, but rather to facilitate personality growth and evolution. If that can be demonstrated, then the therapy is effective by its own criteria, independent of any demonstration of its effects on a group of people with a common disorder. In early research, client populations were specified in terms of things like socioeconomic status, student versus nonstudent status, and gender. But they were not specified by disorder, other than to note that they were generally neurotic.What was measured was positive personality change (through self-concept Q sorts and projective tests, for instance). Several studies found empirical support for the hypothesis that client-centered therapy led to such positive changes (e.g., Seeman, 1965; Shlien, Mosak, & Dreikers, 1962). But these studies disappear by the task forces criteria. A recent meta-analysis (Elliott, 1996) has provided further evidence on the effectiveness of client-centered therapy. Why would this not lead to client-centered therapy being on the task forces list? Bezause (a) not all of the studies are manualized, (b) there are not two manualized studies on the same disorder, and (c) not all studies are studies done on specific disorders. This leaves us with the odd situation of a therapy with substantial empirical support falling into the task

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forces experimental category because of the task forces arbitrary and restrictive criteria.

Therapeutic mini-outcomes. Part of our argument is that the task forces criteria only mandate a therapy as having been shown to work if it has been shown to alleviate specific disorders. While this might be an appropriate criterion for managed cares concerns about what it means to say that a therapy works, it is not an appropriate set of criteria for deciding in general that a therapy has been empirically supported, Rather, a therapy can be said to work if it produces its intended outcomes, and, as we have already indicated, not all these outcomes need be reduction in a DSM-like disorder. Mini-outcomes(Greenberg, 1986) are the particular in-session outcomes associated with particular in-session therapy events. Examples include the use of the Gestalt two-chair technique for reducing intrapsychic conflict between two opposing parts of the personality (Greenberg, 1984), the evocative unfolding procedure for dealing with individualsexperiences of confusing personal reactions (Rice & Saperia, 1984), and Friedlander, Heatherington, Johnson, and Skowrons (1994) study of a change in family therapy from a state of familial disengagement to engagement. Greenberg, Elliott, & Lietaer (1994) list other mini-outcomes found in research on experiential psychotherapy. These include becoming more fully aware of immediate experience and feelings; better understanding of self, problems, and others; experiencing hope and relief; and coming to own or value aspects of the self. These findings are all the more important because session impacts and in-session resolutions (i.e., minioutcomes) have been found to be associated with eventual therapeutic outcome (Greenberg et al., 1994). As we have pointed out, the fact that therapy can be said to lead to such outcomes is clear evidence that these therapies work in the sense of producing certain changes. Furthermore, these changes are important in two senses. First, they are of psychological significance, and if we are as scientists interested in understanding humans and how they change, then we must take these results seriously. Second, some clients want increased insight or greater awareness of feelings and experience, and come into therapy precisely because they are seeking these outcomes. Human science research has been done to explore some of these mini outcomes in greater detail. Watson and Rennie (1994) did a qualitative study of the resolution of problematic reactions (Rice & Saperia, 1984). It was found that clients are quite active in engaging in reflexive self-examination:to articulate their experience in words, represent it to themselves, and then revisionor reconstrue themselves. Elliott et al. (1994) have used qualitative analysis to study insight events in cognitive-behavioral and psychodynamic-interpersonal psychotherapies, and have found that the kinds of insights facilitated differ between these two therapies. Empirical supportfor general humanistic hypotheses. There is also a substantial amount of evidence supporting two basic postulates of our general humanistic model: that (a) the relationship and (b) the client as active agent are the two most important factors in making therapy work, and are more important than specific therapeutic procedures or techniques. Evidence for the dodo bird verdict that all therapies work about the same for most disorders continues to accumulate (Bergin & Garfield, 1994; Seligman, 1999, suggesting the relative nonimportance of technique. Other evidence strongly supports the importance of the therapeutic relationship (Lambert, 1992; Krupnick et al, 19961, and the importance of client agency and

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involvement (Bergin & Garfield, 1994; Bohart & Tallman, 1996;Rennie, 1990). Therefore, an ethical humanistic therapist, who practices by establishing a good therapeutic alliance, and by respecting and mobilizing the clients own active self-healing agency, could be said to be practicing in an empiricallysupported fashion, no matter what particular therapeutic brand name she applied to herself. But not by the task forces criteria, which lead it to dismiss much of the research on which the dodo bird verdict and related conclusions are based. The task force, however, has a vested interest in making the dodo bird verdict disappear. If this verdict were to hold, its whole project disappears. Then there would be no need for the differential empirical validation of different treatments for different disorders. Yet even with manualized therapies evidence for the dodo bird verdic continues to be found (e.g., Babor et al., 1996; Robinson, Berman, & Neimeyer, 1990). There is considerably more evidence for the dodo bird verdict than there is for the isolated instances where differential treatment effects by client condition have been found. Once again, arbitrary choice of criteria invalidates evidence relevant to important aspects of humanistic practice. HOW WE COULD EMPIRICALLY VALIDATE OUR APPROACH We will present one way our humanistic therapy could be empirically supported in its own terms. Recall that we have most basically defined our therapy as working if it provides a certain kind of context or relationship within which clients have the opportunity to engage in certain kinds of self-exploratory activities, more so than they have available in their everyday lives. We posit that the therapist is the treatment of choice, meaning that the key to providing this kind of context is that the therapists responses to the client are highly attuned to what this dient is undergoing or struggling with. The therapist embodies basic humanistic principles, such as being empathic, respectful, inductive, and discovery-oriented. Clients have the support, interaction, and freedom to focus on themselves (Phillips, 1984). This context allows for the possibility for clients to more deeply experience themselves; explore their experience, articulate their experience in words and symbols; think about and more deeply examine the meaning and thrust of their lives; develop a more coherent, integrative, and forward-looking narrative structure for their lives; develop their capacities for intimacy more; become more self-accepting; and develop new plans for further development. Along with this some, clients may show symptom reduction. Others however may not, but rather come to view their symptoms differently (example: view depression as an inspiration to personal self-discovery and creativity; Greening, 1996; Mark Stern, personal communication, October, 1996). We do not posit an efficient-causal relationship between therapist operations and client outcomes. Our context allows and facilitates the possibility for any or all of these changes to come about, but individual clients and individual therapist-client dyads will develop their own idiosyncratic variations on this process, use it in different ways, and will produce their own particular unique and emergent outcomes. Thus it will never be possible to say that our therapy caused these changes, merely that it enabled or facilitated them. With this in mind, we propose a hybrid natural-science/hurnan-science study using a randomized clinical trial, but eschewing the twin criteria of manualization and specification of disorder. Clients who were attracted to the kinds of experiences our therapy provides could be randomly assigned to a therapy condition or a waitlist

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control condition. The therapy sessions could be taped. Clients could fill out postsession open-ended questionnaires on their experiences, and both clients and control participants could keep a weekly journal on how their lives are going. At the end of therapy, in-depth interviews would be done with both groups, and then again at the end of a six month followup. We would expect that clients would report that the therapy experience allowed them to engage in the work of self-exploration and personal problem solving to a much greater extent than they had previously been able to do in everyday life. Indicators of progress in sorting out personal issues, of establishing narrative coherence, of becoming more self-accepting,and so forth, would be found in the interviews with the clients more so than in the interviews with the control participants. Clients would exhibit more differentiation in their views of their experience, they would be clearer about what they were not clear about (i.e., questions that needed asking and answering), and they would be more likely to have discovered new, emergent creative solutions to some personal problems. Their narratives would have become more coherent and organized, attributions and understandings of causality might have changed, characterizations of self and others may have changed, and values and priorities might have shifted. Complex, detailed qualitative analyses of the session tapes, post-session questionnaires, journals, and posttherapy interviews could be used to lay bare the complex trajectories involved in personal evolution, compared to equivalent analysis of the journals and post-therapy interviews of the controls. If individual therapists saw more than one client, then, as the jazz solos of famous jazz musicians have been studied, how therapists individualized interaction and embodied general principles could be studied. At an overall level, therapist adherence to these general principles could be assessed via client post-session questionnaires, or through tape ratings. That this latter is conceivable is demonstrated by a study by Raskin (1974). He found that a wide range of therapists could generally agree on the degree to which different therapists exhibited some general strategic characteristics, such as the degree to which they were generally empathic, generally focused on cognition, or generally valued experiencing.

CONCLUSIONS, IMPLICATIONS, AND RECOMMENDATIONS

We have used a general humanistic model of therapy as an example of how the task forces criteria are restrictive and discriminatory. Our major point is that it is inappropriate for any body to decide upon universal criteria for the empirical support of psychotherapies. In order to pursue scientific knowledge we must adopt an open stance toward empirical inquiry (Feyerabend, 1988), realizing that there are multiple pathways to investigation and support of therapeutic approaches, and not decide in advance on uniform criteria that will actually be counterproductive in our quest to study human change. The task forces criteria not only potentially disenfranchise certain therapies by either forcing them to validate themselves in ways that distort their meaning and purpose o r go out of business, they also restrict empirical inquiry into the nature of human change. They may be doing this to fit into the managed-care market. As such, however, their criteria are not appropriate for other uses and goals of psychotherapy. Using other criteria, equally defensible, other therapies already have been empirically supported (e.g., client-centered therapy).

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BOHART, OHARA, AND LEITNER IMPLICATIONS FOR HUMANISTIC PSYCHOTHERAPIES AND MANAGED CARE

A counterargument that could be raised is that the kind of empirical research we have discussed above (e.g., nonmanualized, not a treatment for a disorder, utilizing qualitative methods) would not make humanistic therapies marketable to managed care or palatable to governmental agencies involved in health-care policy making (e.g., Barlow, 1996). However, if we are to remain a science with integrity, issues concerning appropriate criteria for scientific evaluation should not be decided by what is marketable to outside agencies. Further, we are not convinced that our criteria ips0 facto rule us out of the managed-care market. For one thing, at the very same time that managed care is requiring models of psychotherapy which look medicalized to treat DSM conditions, businesses, through their human-resources departments, are contracting for humanistic services to promote growth. Executives are using personal development coaches, many of whom operate humanistically. It may not be long before they, and consumers, begin to demand freedom of choice in the psychotherapeutic services they are offered. Some health plans now allow consumers the option of seeking out alternatives to traditional medical care in the form of holistic healing practices. If something like this happens with psychotherapy, then the kind of criteria mandated by the task force may become outdated. Simply thinking about this possibility should show the folly in restrictively defining only certain critreria as the appropriate ones for empirical support. We envision a day when a depressed client goes to her HMO and is told You have a choice. You can see Therapist A. Therapist A will diagnose you and then will decide upon a treatment which has been empirically supported for getting rid of your depression. Or you can see Therapist B. Therapist B will not diagnose you. Instead, Therapist B will support, guide, and mentor you as you explore your own experience. The focus of this approach is on personal self-understanding and growth. Therapist B believes that clients have their own self-healing tendencies, and her job is to be with them on their journey. Therapist B does not enter into therapy with any preplanned ideas, but rather uses her own experience to help illuminate the process occurring in the moment between herself and you. This therapists approach has also been empirically supported, but not specifically for depression, because its goal is not specifically to curedepression. Rather, its goal is to help you grow as a person, and its belief is that anyone can do that, given these conditions, and that if you do that, you will find answers to some of the questions troubling you. We will give you 8 sessions of whichever therapy you prefer.

RECOMMENDATIONS First, we recommend that those who write guidelines for psychotherapeutic practice carefully specify what their criteria for empirical support are intended to achieve. Second, we recommend that they carefully note that it is meaningless to specify in advance a one size fits all universal model. We specifically caution against coming up with lists of empirically supported treatments which by implication throw approaches that do not meet the stated criteria into an experimental treatment class. If lists are to be drawn, it should be clearly noted that these lists only serve the delimited purposes of the listmakers and that there are other approaches to therapy which have been empirically supported for other purposes using other criteria which are not included on the list. We specifically recommend that the Division 12 guide-

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lines make clear that the criteria adopted are being adopted to evaluate therapies in a disorder-driven context for managed care. They should also note that standards in philosophy of science change and evolve with time and that we must adopt and advocate an open stance toward what is to be considered empirical support to meet the evolving needs of the psychological community. Finally, we recommend that humanistic and constructivistic therapists do more work developing their methods to empirically support their therapies in their own terms. Some very good work has been done from a human science perspective (e.g., Rennie, 19901, but more, particularly on psychotherapy outcome, needs to be done.

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Zusammenfassung
In diesern Beitrag wird argurnentiert, dass die Kriterien fur empirisch validierte Behand1ungenrestriktiv und wissenschaftlich ungerechtfertigt sind. Sie entwerten Therapien, die nicht mit den Grundannahrnen der Kommission der Division 12 uber die Grundlagen von Psychotherapie in Einklang stehen und sie stellen die Psychotherapieforschung in Frage. Die Kriterien der Kommission basieren auf einem quasimedizinischen Metamodell der Psychotherapie, welches nur darauf abzielt, dem Markt des Gesundheitswesens gerecht zu werden, sie sind aber nicht geeignet fir jene Therapien, deren primare Absicht es nicht ist, eine Storung zu heilen. Wir argumentieren, dass die empirische Stutzung von Therapien auch jene Forschung beriicksichtigen sollte, die sich Methoden bedient, die mit den Grundannahmen einer Therapie kompatibel sind, speziell bezogen darauf, was es bedeutet, zu sagen, dass eine Psychotherapie funktioniert. Weder das Prinzip der Manualisierungnoch die Notwendigkeit, Therapien auf die Behandlung spezifischer Storungen auszurichten, stehen im Einklang rnit humanistischen Grundannahrnen. Vor diesem Hintergrund sollte die Methodologie der Naturwissenschaften nicht der Methodologie der Geisteswissenschaftenvorgezogen werden. Benutzt man Kriterien, die sich von jenen der Kommission absetzen, findet man durchaus betriichtliche empirische Unterstiitzung Mr humanistische Grundannahmen.

R&Umt5 Nous soutenons le point de vue que les criteres pour les traitements ernpiriquement valides sont restrictifs et injustifies, quils pourraient priver de leurs droits des therapies qui ne rentrent pas dans les definitions de la Division 12 Task Force concemant la nature de la psychotherapie, et quils risquent detouffer la recherche en psychotherapie. Ces criteres se fondent sur un rneta-modele medicalis6 de la psychothCrapie cense convenir au marche du managed care. Nous plaidons pour inclure comme support empirique d u n e therapie un type de recherche base sur des methodes qui sont compatibles avec les fondements theoriques de cette therapie, et notamment sur ce qui est cense faire marcher une therapie particuliere. Ni letablissernent d u n rnanuel therapeutique ni Iexigence de Iindication d u n e mCthode therapeutique pour des troubles specifiques ne correspondent aux principes de base hurnanistes. De rncrne, les methodes des sciences naturelles ne devraient pas &re privilegiees par rapport aux methodes des sciences hurnaines. En prenant dautres criteres que ceux de la Task Force, on arrive 2 un support empirique considerable en faveur des hypotheses humanistes.

Resumen Se dice que 10s criterios para 10s tratamientos empiricarnente validados son restrictivos y estin cientificamente injustificados, no reconocen como vilidas las terapias que no comparten 10s supuestos de la Division 12 de la Task Force acerca de la naturaleza de la psicoterapia, y pueden llegar a asfixiar la investigation en psicologia. Los criterios se basan en un metamodelo de psicoterapia de tipo medico, diseiiado para el mercado de las terapias asistenciales que es inapropiado para Las terapias cuyo principal objetivo no es curar el desorden. Nosotros sostenemos que el apoyo empirico a una terapia debe incluir investigaciones basadas en rnetodos compatibles con 10s supuestos de la misma, en particular, el de que una terapia dada funcione. Ni la manualizacion ni el diseiio de terapias para tratar desordenes especificos se ajusta necesariamente a 10s supuestos humanisticos. Tampoco se debe privilegiar la metodologia de la ciencia natural por sobre la rnetodologia de las ciencias hurnanas. Criterios diferentes a 10s de la Task Force dan considerable apoyo empirico a 10s supuestos humanisticos.

Received March 15,1996 Revision Received April 10,1997 Accepted April 17,1997