20

FUTURE DIRECTIONS IN RESEARCH

ON HUMANISTIC PSYCHOTHERAPY
WILLIAM B. STILES

I was pleased to be invited to write this brief chapter on future directions

in research, but I had a few misgivings. “Future directions” can sound like
predictions, for which I have no talent or, worse, prescriptions. I am wary
of individuals or panels who presume to set a research agenda for others,
and I feel ambivalent-uncomfortable and guilty as well as honored-
about assuming that role myself. My discomfort is not so much about such
(misconstrued)prescriptions’direct influence on researchers, who will judge
for themselves whether a recommendation is worth the enormous effort
that any research entails, as about the possible influence on evaluators
(e.g., reviewers of grant proposals or submitted manuscripts), who could use
conformity to the prescriptions unthinkingly to judge a project’s value.
Nevertheless, I do have some observations and opinions about research
on humanistic psychotherapy, which I am happy to offer here (and elsewhere,
in references I have cited below) for considerationby future researchers. After
an initial section, meant as an endorsement of methodological pluralism, I
comment on several categories of research on humanistic therapies.

THE FACTS ARE FRIENDLY

When Carl Rogers (1961, p. 25) wrote, “The facts are friendly,” he
was referring to scientific research. Nevertheless, humanistic theorists and
therapists have often considered research as dehumanizing. Perhaps psycho-
logical research’sfrequent focus on mechanical cause and effect and on linear
relations among quantified variables seems to constrict the understanding of

I thank Robert Elliott, Lam, M. Leitner, and the editors of this volume for comments on drafts of
this chapter.

605
human experience (see discussion by Walsh & McElwain, this volume,
chapter 8). A sad consequence is that humanistic therapies have been
researched less than they should have been. I believe that this view of
research is too narrow, based partly on a mistaken impression that psychologi-
cal research must imitate research in chemistry or engineering.
Science encompasses any comparison of ideas with observations. Num-
bers are admittedly remarkable; compared with words, their meaning is
relatively stable across time and people, so they allow scientists to say more
or less the same thing to everybody. Likewise, experimental designs and
statistical analyses are to be admired for their precision and potential general-
ity. However, many of the most interesting phenomena with which humanis-
tic theories and therapies are concerned, such as the unique life experiences
of individuals, cannot be well represented as numbers or as variables suscep-
tible to manipulation or control using currently available techniques
(Stiles, 1993).
Humanistic researchers need not let their own or others’ admiration
of precise methods trap them into “looking under the lamppost’’ (after the
story of the inebriated man who dropped his keys in a dark alley but looked
for them under a streetlight because the light was better), that is, into using
methods that seem elegant but are nevertheless inappropriate for the topic
of interest. If a topic cannot be adequately addressed using available experi-
mental designs and linear statistical analyses-and many cannot-then
other observational techniques are available. Among these are case studies
and other qualitative approaches, such as idiographic studies, ethnography,
ethnomethodology, grounded theory, protocol analysis, discourse analysis,
conversational analysis, constructivist approaches, phenomenology, or her-
meneutic investigation (e.g., see Rennie’s chapter 4,this volume). Distinc-
tive characteristics of qualitative research that could make it suitable for
addressing humanistic topics may include the following: (a) results that are
reported in words rather than only in numbers, (b) use of many descriptors
rather than restriction to a few common dimensions or scales, (c) use of
investigators’ empathic understanding of participants’ inner experiences as
data, (d) understanding and reporting of events in their unique context,
(e) selecting participants or texts or other material to study because they
are good examples rather than because they are representative of some larger
population, (f) reports that use alternatives to traditional didactic discourse,
including narratives or hermeneutic interpretations, (8) accommodating
unpredictability due to sensitive dependence on initial conditions (small
initial events may have huge consequences), (h) empowering of participants
considered as a legitimate purpose of the research (e.g., encouraging them
to change their social conditions), and, above all, (i) tentativeness in inter-
pretations (Stiles, 1993, 1999b). Even though the conclusions of qualitative

606 WlLLlAM B. STILES

research may be tentative, however, the gain in realism can compensate
for losses in generality (see Levins, 1968).
Case studies in particular are underused (Farmer, 1999; Stiles, 1995).
Of course, case studies have the usual weaknesses of anecdotal research:
selection of data, possible distortions of introspective reports, investigator
biases, lack of generality, and so forth. But humanistic therapists are familiar
with the need to hold information tentatively in clinical contexts, and they
can similarly report case-based investigations without claiming certainty or
generality. A multiple case study approach (Rosenwald, 1988) might be
particularly well suited to psychotherapy research. Therapists who have
treated similar clients might collaborate in assembling multiple cases around
a common theme for research reports.

OUTCOME RESEARCH

Randomized clinical trials (RCTs) of humanistic psychotherapies re-

main politically necessary, and outcome research using other designs (e.g.,
pre-post single-group comparisons) are also politically valuable. RCTs are
a statistical adaptation of the experimental method, which is the closest
science has come to a means for demonstrating causality. RCTs may be
flawed for many reasons (Haaga & Stiles, 2000), and their value for determin-
ing mental health policy is controversial (Bohart, O’Hara, & Leitner, 1998;
Elliott, 1998; Henry, 1998; Strauss & Kaechele, 1998). The question “does
it work?” is so salient, however, that other questions seem to remain in the
background until this one is addressed.
According to the latest update of a continuing meta-analysis (Elliott,
1996; Elliott & Greenberg, this volume, chapter 9; Elliott, Greenberg, &
Lietaer, 1994),humanistic therapies have shown mean pre-post effect sizes
in the range of 1.1 to 1.3, which are very respectable effects. In addition
to Elliott and Greenberg’s report for process-experiential therapy, several
other chapters in this volume also reported positive effects of specific human-
istic treatments; for example, Johnson and Boisvert (this volume, chapter
10) pointed out that outcomes of relational enhancement and emotionally
focused therapy for couples compare favorably with those of the best-
researched alternative treatment, behavioral marriage therapy. However,
these reviews were based on relatively small numbers of studies, which were
themselves based on small numbers of clients and (as usual) open to challenge
on methodological grounds.
Researchers designing RCTs and other outcome studies need to be
cognizant of the limitations and likely results. For reasons that have long
been puzzling (see Rozenzweig, 1936), most alternative psychotherapies

FUTURE DIRECTIONS IN RESEARCH 607

appear to be equivalently effective (Lipsey 6r Wilson, 1993; Wampold et
al., 1997), despite the demonstrated diversity of theories and techniques
(Stiles, Shapiro, & Elliott, 1986). This paradoxical equivalence is robust,
and it seems unlikely that future comparisons will show humanistic therapies
to be hugely more effective or less effective than other therapies. Even
when results favoring one treatment are found, they may be at least partly
attributable to the investigators’ allegiance (including unintended effects
of allegiance OD how the compared treatments were implemented) more
reliably than to the ostensible treatment approach (Luborsky et al., 1999).
Perhaps the technical differences among therapies are overshadowed by the
common features (e.g., mutual responsiveness in a helping encounter) or
by case-to-case variation in how each treatment is realized.
An important side benefit of RCT designs and other large-scale out-
come studies is providing a context for other sorts of psychotherapy research.
Data collected in the course of conducting an outcome study, including tape
recordings of sessions, can be used to study alternative outcome measures,
individual differences, and the psychotherapeutic process. Though politically
less salient, these additional areas of research may be scientifically more
informative.

OUTCOME MEASUREMENT

The political purposes of outcome research demand (a) broadly ac-

cepted outcome measures of (b) criteria that are common across clients that
(c) are easy to collect. The lowest common denominator seems to be symp
tom intensity, assessed through checklists completed by clients, therapists,
or external evaluators. Politically more potent, but far more difficult to
assess (and much less used), are indices of life changes that have economic
implications: job-holding, divorce, hospitalization, or other use of health-
related resources.
As noted in many of this volume’s chapters, humanistic conceptions
of therapy’s purpose and effects go beyond reducing symptom intensity.
Clients undoubtedly notice and care about changes in style of working or
relating and other idiosyncraticchanges that may be only tangentially related
to the usual criteria used in outcome research. There may be many different
outcomes that yield similar levels of symptom relief (Stiles, 1983). Indeed,
as Walsh and McElwain (this volume, chapter 8) pointed out, some symp-
toms, such as existential anxiety, may be productive, and therapists and
clients may sometimes consider treatment successful even when it leaves
symptom intensity unchanged.
Research to assess humanistic therapy’s specific effects-as contrasted
with its efficacy or its effectiveness-demands continuing creative ingenuity.

608 WlLLlAM B. STILES

Rating scales designed to assess dimensions beyond symptom intensity or
global evaluations can be useful in this respect. Q-sort measures represent
a still-underexploited alternative (see Ablon & Jones, 1998). Changes that
are unique to individuals can be documented using qualitative approaches.
Of course, anecdotal or other ad hoc measures may not be potent
politically in justifying the cost of psychotherapy. Multiple measurement
approaches-symptom intensity checklists and humanistically informed
qualitative accounts-probably are best used in parallel. In their own think-
ing and writing, researchers may wish to distinguish between political and
conceptual contributions, but they would be foolish, I think, to restrict their
measures to only one of these categories.

DIAGNOSIS AND DIFFERENTIAL TREATMENT

Placing people in categories is potentially dehumanizing. O n the one

hand, diagnoses can oversimplify and distort perceptions of the person to
whom they are applied. For therapists, the danger lies in responding to a
textbook concept or a stereotype rather than to the client’s immediate and
unique life experience. Diagnoses may induce a false sense of security, a
feeling that one knows more about another person than one actually does.
On the other hand, ignoring diagnosis or psychological assessment
can be a form of anti-intellectualism, of which humanistic therapists are
sometimes accused. One must use categories to think at all. Whether the
categories come from diagnostic manuals, textbooks, supervisors, parents,
folklore, or television, there is a risk of reification-confusing the concept
with the reality. Stereotypes and other preconceptions can be dehumanizing,
oversimplifying, and distorting regardless of where they come from. Insofar
as therapists cannot avoid having some sort of preconceptions, the goal
must be to hold those preconceptions tentatively.
I suggest that therapists and researchers serve clients best by gathering
a rich repertoire of categories, learning about the full range of human
experience from whatever sources are available, including research results
and diagnoses. In dealing with clients, responsible humanistic therapists
apply all knowledge tentatively, always comparing their current understand-
ing with new observations and always ready to withdraw inferences that
are contradicted by their client’s individual experience. Bracketing-trying
to ignore diagnostic information in listening to clients-may help therapists
avoid treating people as diseases, but it risks overlooking useful perspectives
that diagnoses can add.
Diagnostic categories need not be dehumanizing, so long as therapists
use them to understand rather than to substitute for understanding their
clients’ personal experience. Case studies have suggested that the common

FUTURE DIRECTIONS IN RESEARCH 609

clinical manifestations reflected in formal diagnoses may reflect common
client experiences (Bohart, 1990; Schneider & Stiles, 1995). People who
appear as depressed or as borderline or as schizophrenic may experience
the world in distinctive ways that differ from their therapists’ experience.
Knowledge of a client’s diagnosis, and the distinctive experiences it may
entail, may thus help a therapist understand what the client is trying to say
more quickly or more deeply. The work of Prouty (this volume, chapter 19)
takes important steps in this direction by focusing on repertoires of therapeu-
tic techniques useful for working with people with particular diagnoses (e.g.,
schizophrenia). Such research might be expanded by shifting the focus
slightly to describe the experiences of these clients. Explicitly humanistic
alternatives to traditional diagnostic systems (e.g., Leitner, 1995; Leitner
& Pfenninger, 1994)may offer additional, particularly useful ways for human-
istic therapists to understand clients; however, even humanistically inspired
categories and dimensions must be applied tentatively.
Reification of diagnostic concepts can be problematic on many levels.
For example, it can seem a matter of professional ethics and responsibility
to provide the best-researched treatment for each client’s problem. If prob-
lems are required (e.g., by research protocols or third-party payers) to be
defined in terms of diagnoses or similar descriptors (e.g., depression, phobia,
or panic), then it may seem that research on treatments must target diagnos-
tic categories to address treatment selection in an ethical and responsible
way. Research in which the treatments are understood as addressing the
unique needs of individuals can be seen as irrelevant. And delivering treat-
ments that lack diagnosis-specific efficacy data may be viewed by some
people as unethical.

PROCESS RESEARCH

Process research recognizes that there is no long-term change without

short-term change. It investigates how changes take place within and be-
tween sessions.
The most powerful results reviewed in this book, in my opinion, were
those dealing with replicated categories of events within sessions-broadly
in line with the concept of the events paradigm described by Rice and
Greenberg (1984). Some examples include (a) research on markers of readi-
ness to engage in experiential tasks by Greenberg and collaborators, reported
in several chapters (e.g., Strumpfel & Goldman, chapter 6; Elliott & Green-
berg, chapter 9; Johnson & Boisvert, chapter 10) and Watson’s (chapter
14) related extension to markers of readiness for types of empathic responses;
(b) processing proposals research by Sachse and Elliott (chapter 3 ) ; (c)

610 WlLLIAM B. STILES

Rennie’s (chapter 4) work on deference and story-telling; (d) identification
of ruptures in the therapeutic alliance (Asay & Lambert, chapter 17; simi-
larly, the “disturbances in reflexivity” reported by Rennie, chapter 4); and
(e) Prouty’s (chapter 19) categories of contact. Stages of group development
(Page, Weiss, 6r Lietaer, chapter 11) also are often signaled by “barometric
events,” which could similarly be considered as markers of participants’
internal states or readiness to engage in particular tasks (Stiles, 1979). The
results of these investigations link recognizable markers with readiness for
specific types of interventions in clinically useful ways. Moreover, because
they describe psychotherapy at a level close to that used in psychotherapeutic
theories, these process studies address the theories better than outcome
research can. For example, the descriptions of the softening of one voice
toward another in a two-chair exercise is not only a clinically important
sign but also a theoretical elaboration of the process by which internal
conflicts are resolved.
Therapy theories are meant to explain how therapy works. The bald
hypothesis that a treatment is effective, which is what outcome research
tests, is a relatively undifferentiated consequence of the theory. Even the
repeated finding that positive therapeuticrelationships (alliances)are associ-
ated with positive outcomes glosses over the important intermediate steps.
By contrast, events-paradigmresearch traces sequenceswithin sessions.Typi-
cally, the sequence begins with an observable marker, which signals some
internal state of the client, which implies some readiness for a therapeutic
intervention, whose effect can be gauged by the client’s subsequent behavior.
In discussing process research, I should also mention a limitation:
What may seem the most obvious strategy for assessing the effect of process
components-measuring them and correlating them with measures of out-
come-is blocked by the phenomenon of responsiveness, the fact that partici-
pants’ behavior is affected by emerging context (Stiles, Honos-Webb, &
Surko, 1998). Therapists normally try to respond to a client’s emerging
requirementswith interventions that are appropriate, given their theoretical
approach, the client’s personality and background, and the therapeutic
context. To the extent that they succeed,clients tend to experienceoptimum
levels of those interventions. Clients who need less tend to receive less,
and-insofar as they still got as much as they needed-their outcomes tend
to be just as good as those of clients who needed more and got more. As
a result, levels of the process components do not predict outcome. Crucially
important process components may have null or even negative correlations
with outcomes (Stiles, 1988). Conversely, the relative strengths of process
variables’ correlations with outcome are uninformative. Variables with null
correlations may be as important or more important than variables with
significantpositive correlations. Thus, process-outcome correlations are not

FUTURE DIRECTIONS rN RESEARCH 61 1

to be trusted. For an illustration and debate of this point, see the series of
articles by Stiles and Shapiro (1994), Silberschatz (1994), Sechrest (1994),
Stiles (1994, 1996), and Hayes, Castonguay, and Goldfried (1996).
Ofcourse, reliable positive correlations generally have interesting ex-
planations. However, these may not be the obvious ones because of respon-
siveness or because of possible confounding variables.
The responsiveness problem has frequently been overlooked, and a
great deal of process research (including mine!) has futilely sought linear
process-outcome relations. Alternative research strategies may require re-
conceptualizing the problem (Stileset al., 1998).Unfortunately, researchers’
and reviewers’ focus on correlations with outcomes has often obscured
important achievements in process measurement, in precise descriptions of
what happens (e.g., of therapists’ and clients’ verbal and nonverbal behav-
ior), and in comparisons of the process across roles (e.g., therapist and
client), treatments (e.g., client-centered,Gestalt, psychoanalytic, and cogni-
tive-behavioral), and settings (Stiles, Honos-Webb, & Knobloch, 1999).

HUMANISTIC CONCEPTS, HEROES, AND VALUES

Psychotherapy is a laboratory as well as a source of ideas’forresearch

(Stiles, 1992)and a treatment (Greenberg, 1991;Stiles, 1999a).Psychother-
apy offers exceptional opportunities to study fundamental conceptions of
humanistic theories. Examples of such topics include the role of interpersonal
power (e.g., the therapist’s over the client), the psychology of focusing and
felt shifts, the softening of negative emotion in two-chair exercises, the
assumption that emotion represents information about an experience’svalue,
the effects of directed repetition and exaggeration of nonverbal behaviors,
and the nature of the self. Research based in psychotherapy could address
issues that divide humanistic therapies. For example, Rogers’s (1951, 1959)
assumption of an organismic valuing process-that a person’s value judg-
ments are fundamentally trustworthy-was an underpinning of his radically
nondirective approach. The scope and limits of this assumption are clearly
controversial within humanistic therapies, illustrated by the varied discus-
sions of directive interventions in this book. Methodological ingenuity is
needed to find ways to investigate the alternative conceptions.
Humanistic therapies have heroes-for example, Carl Rogers and Fritz
Perk-whose visions have defined the field. Their deep understanding al-
lowed them to be effective, and we as therapists who follow try to reproduce
their understanding, so we can be equally effective. The heroes’ vision is
not conveyed by a single reading of their words. On each rereading, their
words (and their tape-recorded actions) take on new meanings. We seem
to understand more of what they meant each time we return. To put it

61 2 WLLIAM B. STILES
another way, the major humanistic theories are partly implicit and continu-
ally emerging.
The deep appeal of the heroes’ visions can make them competitors
with research as means of quality control on ideas. That is, to assess the
quality of our ideas, we may turn to the words of the heroes rather than to
observations. Perhaps this is not entirely misguided. Research based on a
weak understanding of the vision (e.g., reductionistic operationalizationsof
humanistic concepts) is dismissed by proponents and hence has little impact
on quality control. Comparing a new idea with the writings of the master
may, paradoxically, offer a better test of its fit with clinical reality. However,
there are obvious long-term dangers in such a closed system, in which ideas
are judged only in relation to other ideas. Part of the research task is to
articulate the vision in ways that are simultaneouslyacceptableto proponents
and susceptible to observation.
In good research, when the ideas are compared with the observations,
the ideas are thereby changed; they are strengthened, weakened, qualified,
or elaborated. Thus, good research on humanistic concepts must put those
concepts at risk. The risk may be compounded for humanistic researchers,
whose concepts may overlap extensively with their values. Research will
not tell us what is good, though people can use research results to argue
for their own views and values. Research is most productive when researchers
have the courage to face potentially unfriendly findings with an underlying
confidence that the facts are friendly.

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