“I was the father without a clue.”
Randall C. Wyatt: Your work has focused on gender, the psychology of men, the problems with traditional masculine socialization, psychotherapy with men, and fatherhood, in addition to your work as APA (American Psychological Association), President and the evidence-based practice of psychology. Let’s start with the psychology of men and your upbringing. What was your upbringing like?
Ronald Levant: I was raised in a really tough neighborhood, and where I grew up, if a boy starts to show vulnerability, he's also so violated the male code as to warrant severe punishment.
RW: Typically, if a boy shows he cannot withstand or deal with the teasing it does not bode well for him as a kid.
RL: Yes, I witnessed scenes as a child where boys were beat up by other boys for crying.
RW: You grew up in Los Angeles? Whereabouts in LA?
RL: Southgate. South Central Los Angeles. No, I wasn't a member of the Crips and Bloods.
RW: But it was a tough neighborhood?
RL: Yes. At that time, South Gate was all white and it bordered Watts, which was all black. Southgate was pretty much a blue collar town. There were two major factories in the town then, Firestone and General Motors, and most of the fathers of my friends worked on the line. So it was a working class, tough neighborhood.
RW: Did these early experiences spark your interest in men’s psychology and psychotherapy with men?
RL: Actually, it was being a divorced, semi-custodial father. My wife and I lived in California. Then she moved to New York, and I moved to Boston, and we worked out an arrangement where I had my daughter for the summers. And I would travel several times a month to visit her in New York.
But the visits when she lived with me did not go well and I felt like I was the father without a clue. I didn't really have a good idea of what a father was supposed to be, because when I thought about my own dad, his idea of having quality time with me and my brother was to have us do some work and he'd supervise.
As a psychologist, young assistant professor at Boston University, responsible for teaching the courses in family psychology and having a research program on parent training,
I felt like I was a fraud, because here I am an expert in parenting and family stuff, and yet, I'm so ineffective with my own daughter.
I felt like I was a fraud, because here I am an expert in parenting and family stuff, and yet, I'm so ineffective with my own daughter.
And like most men, I didn't talk about it with anybody. Again, I was a fairly traditional masculine guy and I didn't talk about it. Just sucked it up and tried to keep doing it, until I saw the movie Kramer vs. Kramer (1979).
RW: I remember that film; it was talked about a great deal, with Dustin Hoffman and Meryl Streep. Did it hit you right away?
RL: Not right away. I had to think about it for a few days, frankly. It led me to realize that it wasn't a case of my personal inadequacies, though I might have been inadequate is some ways. It was more of a case that this was really a shift in roles for fathers, in that men of my generation were doing things that our dads never did. And maybe we weren't really well-prepared for it. Maybe we could get prepared for it. And so that led to a whole chain of thinking that was the proverbial fork in the road in my career.
RW: And then you began to focus on the study of fathering?
RL: I shifted from parent training to fathering. I started the Boston University Fatherhood Project a few years later. I discovered this lack of emotional self-awareness in my fatherhood work. I used to run these fatherhood courses where we would get six or eight guys to meet together for eight weeks and we would teach them a little bit about fathering. We had a grant that allowed us to purchase an incredible amount of video equipment. Video was very cool in the early '80s, and we had a big room lined with video decks, monitors and special effects generators, microphones hanging from the ceiling, and three tripods with cameras in the middle of the room; so when the guys would come into the room for the first time, they would be just blown away. They'd say, "Wow, these guys have some really cool equipment."
And we'd tell them, "We'll teach you how to be a better father the same way you might have learned how to play a sport like golf or tennis. We'll videotape it, do the instant replay, analyze how you could do it better, and try it again. And we'll practice." A very hands-on approach.
RW: One thing I have really appreciated about your work is that you join with the men and use sports metaphors, which many men can relate to. On that note, one of my early supervisors used to say to men in couple’s therapy, “If Michael Jordan only dribbled with one hand; they’d be able to figure him out really quickly and be able to defend him easily. You’ve got to be able to dribble with both hands. And you know how to think and be logical but you’re ignoring the other side of it, your emotions, which can be learned too.”
RL: That's excellent.
RW: Instead of forcing these men into some therapy-contrived way to express emotions, as in, “How do you feel now,” you really join with the men and say “we.” A lot of men are ashamed or embarrassed to come to therapy since they think it won’t relate to their way of thinking. The traditional therapist says “How do you feel? What are you feeling now?” The traditional male replies, “I don’t know” and leaves feeling more inadequate or that therapy is just not for them.
RL: Right. And then, "What's wrong with you?" From what I've said about my background, you can see that it's not that hard for me to empathize with traditional men. A lot of my friends growing up, myself and my family were traditional men, so it's not a stretch for me. I don't have to imagine it, I lived it. Having been trained in the Rogerian tradition, I want to start off by being as empathic with their experience as I possibly can be.
RW: Did getting into the psychology of men and fatherhood change your relationship with your daughter?
RL: Not right away because the fact that I got into this work didn't have an immediate impact on me. I probably didn't really fundamentally change until later when I went into analysis, which would have been in the later '80s. I went into psychoanalysis for four years and, regardless of what the empirical research says about it, it worked wonders for me.
RW: How so?
RL: Psychoanalysis helped me kind of get through a lot of my own constraints as a human being, some of which were about masculinity and some of which were unique to me, but it was a marvelous experience. I'm really glad I did it. And I think it obviously helped me and my relationships.
You know, I have a good relationship with my daughter now. I have a great relationship with my grandsons. So it didn't work out too badly.
RW: Let’s talk about your work on the psychology of men and gender. Where have we been and where are we now?
RL: When we talk about gender and men in particular, where most of my own work lies, we were pretty blind. Most of the key, long term studies on personality development were done on boys and men at Berkeley and Harvard. And that basic personality development, personality theory, and developmental psychology was the psychology of boys and men until the feminists came along in the '70s and said, "Whoa, women are not simply a deviation from male development. Let's study females, too." So there was a period in time where psychologists thought it reasonable to study only men.
RW: You make another point in your work: that psychologists in their research were studying men a great deal, but in the clinical world, psychoanalysis, it was men studying and treating women, who were the patients. Such irony.
RL: That is a very ironic thing. I'm working with a group in Division 51 of APA, the
Psychology of Men and Masculinity, writing guidelines for the psychological treatment of boys and men. We just met a few days ago at the University of San Francisco— we were writing the preamble— and we had to focus on that very same irony because personality and developmental psychology really was based on male samples, but the whole approach of the psychotherapeutic endeavor was, as you pointed out, based on the idea of men treating women.
Like Freud and Breuer with their female patients they considered hysterical. And it pretty much continued that way through the '60s. So our models of psychotherapy have to be revised, really have to be revised radically.
RW: Even the most famous videos in the psychotherapy field… what video do you think of?
RL: Well, the one that would come to mind for me would be Rogers, Perls and Ellis with Gloria.
RW: Exactly. And that’s what a lot of psychologists and therapists were trained on in their graduate programs.
RL: Your mention of the Gloria video makes me think about something related, it's a bit of trivia. I was trained in the client-centered school. My advisor and professor was John Shlien, who trained with Rogers. Shlien and I put together a book in the '80s called Client-Centered Therapy and the Person-Centered Approach in which Carl Rogers contributed two essays, one of which was a story of his continuing relationship with Gloria. Gloria contacted Rogers after the filming and they developed a lifelong relationship as a result of that half-hour interview. She became very attached to him. She died tragically in her 50's of cancer, but she became friends with Carl and his wife, and would visit. And so it's a remarkable essay on what a 30-minute interaction can create.
Traditional Masculinity is Hazardous to Men’s Health
RW: Now let’s jump into the psychology of men. For a long time, in the ’60s and ’70s in particular, the whole idea of men and women being different was frowned upon, that the sexes were not so different after all. Now we see books and studies on Mars and Venus, on gender communication differences. It seems the pendulum goes back and forth in our culture with politics playing as much a role as the research itself. Where can we begin with this discussion without getting lost?
RL: The bottom line to it all is that men and women are really not that different. We're talking about biology here. Sex. You know, male, female.
Going back to the 70's, when Maccoby and Jacklin did the first kind of major synthesis of the psychology of sex differences, all the way up to Janet Hyde's recent article in the American Psychologist (The Gender Similarities Hypothesis). If you look at any kind of behavioral, psychological, or cognitive traits, what you will find is that there are only a handful of small mean differences, and you will find overlapping distributions. And you'll find within those distributions that, say, males are higher in this trait than females, and you'll find lots of females who are higher than lots of males. Imagine two bell curves with the means very close together, you can see that there's just lots of overlap. So Hyde says, "Let's talk about gender similarities," and that's really true.
But she's misusing the term "gender." It's really sex similarities. It's about biology. Males and females are not that different.
RW: Ok, how are you using gender?
RL: Gender is masculinity and femininity, actually, and in many ways they are like polar opposites. Masculinity and femininity are the ways in which we socialize boys and girls and the ways in which we relate to adult men and women that reinforce or punish certain behaviors. Masculinity is the antithesis of femininity. Whereas men are socialized to traditional masculinity, which would have men be tough and aggressive, women are expected to be nurturing and caring.
We have an ideology about gender that varies within subcultures and societies and is something that I've spent 15 years studying, actually, looking at masculinity ideology. And there tends to be a certain amount of adherence to what my colleagues and I define as traditional masculinity ideology, which is the notion that
men should avoid anything that hints of the feminine, restrict the expression of emotions, be aggressive and dominant, be extremely self-reliant, be studs and always be ready for sex.
men should avoid anything that hints of the feminine, restrict the expression of emotions, be aggressive and dominant, be extremely self-reliant, be studs and always be ready for sex.
RW: The strong cowboy and the Marlboro man.
RL: Yes. The traditional, macho version of masculinity is still adhered to in varying degrees within societies and subcultures. I developed the Male Role Norms Inventory when I was at Rutgers back in the late 80's. It measures seven norms of traditional masculinity ideology and nontraditional masculinity ideology. I used that to study African American males and females, European American males and females, and Latino males and females in this country and abroad. We looked at Russians versus Americans, Chinese twice, before and after the NGO Conference on Feminism in Beijing. And my collaborators have studied it in Japan, South Africa, and Pakistan. So we have quite a bit of data, and we've recently developed a parallel measure for women called Femininity Ideology, a scale which we're just now studying that looks at five norms of traditional femininity ideology.
So ideology or the belief about how men and women ought to behave is a very powerful construct. There are a number of masculinity constructs that have been derived from this paradigm. One is the endorsement of traditional masculinity ideology, the second is conformity to male norms, the third is gender role conflict, and the fourth is gender role stress. And these four constructs—all of which are measures developed by myself and my colleagues — have been used in hundreds of studies, and one of the things that you find is that the higher the level of masculinity, the more the problems.
RW: The more masculinity, the more the problems? Say more about that.
RL: In my scale, the greater the endorsement of traditional masculinity ideology, the more likely it is that the person is alexithymic, which means they have an inability to put emotions into words.
They are more likely to endorse coercive and harassment attitudes towards females. For boys, using a similar measure to mine, they're more likely to have drug and alcohol problems, have early sex and drop out of school. Using Jim O'Neill's measure, The General Conflict Scale, they're more likely to be depressed and have relationship issues.
The long and short of it is that traditional masculinity is hazardous to men's health.
The long and short of it is that traditional masculinity is hazardous to men's health.
RW: It’s not uncommon for a man to come into therapy and say something like, “I was taught not to show my feelings. I was taught to be tough, to ignore those things. I don’t really think I need to be here, therapy is not for me.”
RL: When a man comes into therapy that man could be anywhere on a scale from one to 100 in terms of where they are in their masculinity and I think one of the first messages I would say to clinicians is: think about that. A man is not a man is not a man, but a man may be hypo-masculine, hyper-masculine or somewhere in between, and that's going to be a big difference in how they're going to respond to therapy.
I've created an instrument, the Normative Male Alexithymia Scale, which is available free in the journal Psychology of Men and Masculinity. It's a 20-item scale that you could administer relatively easily to your clients that would give you an indication of whether or not they are likely to be alexithymic. It's a good instrument, only twenty items, with strong reliability and validity, so it's a fairly easy way to assess it.
The fact is, you can assess how traditional a man's view—your client's view—is of masculinity. That's going to make a big difference in how you're going to want to approach him.
RW: In your video, Effective Psychotherapy with Men, you assessed, in session, how your male client made sense of his emotions.
RL: You can probably get a good sense just from the initial encounter by how the man responds to questions, and you might ask him to describe how they felt in certain circumstances, to see whether they're capable of describing how they felt. And men do vary. Again, we have to think of masculinity, not men. There are some men who have not been reared to conform to traditional masculinity or have gotten over it and are fully capable of experiencing and expressing a wide range of emotions. There will also be men who are harshly socialized, maybe even punished for any deviations to the male code. They might have even been traumatized for showing non-stereotypical feelings and have a really hard time answering your questions and will feel ashamed of themselves for even trying to express vulnerability.
Mistakes Therapists Make Working with Men
RW: Let’s focus on that traditional man, because it is that man with traditional masculinity that’s difficult for many therapists. Therapists are used to clients that come in talking about their feelings. They want a verbal, expressive client.
RL: They want a client who's more like a stereotypical female. A man that exhibits the kind of openness to emotions that is ascribed for women and that's an essential core component of femininity. And some men are indeed like that.
But as you point out, you don't need a special training video to learn how to work with those men. You can apply what you already know, and it will work. But the man who doesn't want to be there — his wife forced him to be there. His boss said, "Look, if you don't do something about your lateness" or, "If you don't do something about your aggression." Or the man runs into a few DUIs and has a substance abuse problem and is forced in. Oftentimes, those men don't come voluntarily. They're forced in by circumstances. And so it's a very delicate act to get them engaged.
RW: Can you tell us some of the things you think about when trying to get these traditional men engaged?
RL: I want to connect with what brought them there. Their wife told them to come but they didn't have to come. Okay, you came. So therefore, you must want to preserve your marriage, and you probably want to figure out what you can do about it, right? So I try to start building the alliance with their motivation for being there. There's some motivation. Let's find out what it is. How can we build on it? I try to connect that to my assessment of where they are, if this man is also alexithymic, as I did in the video.
RW: And what if they are alexithymic?
RL: If the man is alexithymic, as Raymond is in the video, I will give a little introduction to masculine socialization: "We men were raised in such a way that we felt it was really inappropriate to express vulnerable emotions, to even dwell on them too much. But the fact is, for you to resolve these problems, you're going to have to learn a lot more about your emotions than you've ever known. The good news is there's a short way to get there. We have a structured method for teaching men how to learn to identify and process their emotions."
You'll encounter lots of resistance along the way. In the video, I am going over the emotional response log with the client and he says, "I can identify 10 emotions but I've still got a problem to deal with."
I came back and I said, "Well, yes, indeed. You do. But I think you're going to be in a much better position to deal with the problem if you kind of know what you're feeling and process that rather than stay stuck in being angry, say, at your shop for delaying the repair of your car."
RW: What kinds of reactions do you get from that, or what resistances emerge?
RL: They might come up with other kinds of resistance, like a common thing I've heard men say is that if they learn how to express their emotions they'll have no choice but to express them. And I say, "Well, actually no.
You're going to have more choices than you have now. You only have one choice now, which is not to express your emotions."
You're going to have more choices than you have now. You only have one choice now, which is not to express your emotions."
And in Raymond's case, to somaticize it, you get a headache or a stomachache. Or in some other man's case, to numb himself by drinking or chasing women, or whatever the maladaptive method that has evolved in that man's life for dealing with psychological distress. And so, "You really have limited choices now. If you can identify and think about your emotions, that is, route it through your cortex rather than simply have it go from your limbic system to your musculoskeletal system, you can choose."
RW: From your emotions to your body, use your mind in between.
RL: That's it. You said it more simply than I did. (laughter)
RW: Reframing.
RL: But that's exactly what it is. If you think about what happens in the socialization of boys, a lot of boys really are humiliated around the expression of vulnerable emotions. "Big boys don't cry," or worse, somebody teases them or picks on them and they show vulnerability and their friends laugh at them or beat up on them, depending on the kind of neighborhood they live in.
RW: What mistakes have you found that therapists commonly make in working with traditionally masculine men, and what can therapists do to work better with these men?
RL: The mistake both male and female therapists make is to really not be aware of how the differences in men and how masculinity affects men's functioning. I think that it's really a knowledge thing. Unless you've taken a course in gender issues in psychotherapy, you're probably not likely to know about this. So to not stop and think, "What kind of man am I dealing with? To what extent has he been affected by masculinity? How alexithymic is he? How am I going to work with him? How much shame does he have about just being here?" If he's very traditional, he's going to be feeling very ashamed. So just simply not knowing some of these front-end issues and that really have to factor into the very initial minutes of your meeting. I think that's one of the first things.
RW: Instead of, “This guy’s annoying. He doesn’t talk about his feelings, doesn’t say anything emotional or immediate, why is he here, what is his problem?”
RL: Exactly. Just like a lot of wives find men annoying and they think that they're just being obstinate:
"I told you I want to talk about your emotions. What's wrong with you? Please share your innermost feelings with me. What the heck's wrong with you? Why aren't you doing that?"
"I told you I want to talk about your emotions. What's wrong with you? Please share your innermost feelings with me. What the heck's wrong with you? Why aren't you doing that?"
RW: And do you find when you work with men that they can change on these things and are they grateful that they have?
RL: Yes, and I actually now have some hard data. I did a pilot study of a flexible, manualized treatment and we did a pilot study with a group that received that treatment and another group that did not. We used the
Normative Male Alexithymia Scale and the
Male Role Norms Inventory. We showed that after six sessions, we were able to significantly reduce the men's scores on alexithymia and on the endorsement of traditional ideology.
So not only do I have clinical, anecdotal case study evidence from treating dozens of such men when I had my practice in Boston, but now I actually have at least pilot study data—not a randomized clinical trial, just a comparison group—that show that this kind of treatment does help men reduce their alexithymia and reduce their adherence to strict male norms.
RW: To switch to another important part of your work as the President of the American Psychological Association in 2005, you were instrumental in creating the APA Presidential Task Force on Evidence-Based Practice in Psychology. Could you tell us how that all came to be?
RL: Sure. In 1995, APA Division 12, the Division of Clinical Psychology under the leadership of David Barlow, established a task force on empirically validated treatments, and took a rigorous scientific approach to practice focused on empirically validated treatment. The treatment had to be subjected to two randomized clinical trials using a manualized treatment, using measures that had good reliability and validity. They had a list of criteria, which would be considered the highest standard for experimental clinical research, and as a result of that, they generated 8 treatments, most of which were cognitive-behavioral or behavioral. This task force identified 18 specific disorders that met this criteria and could be treated with manualized treatments. And this was disseminated as a list of empirically validated treatments. It was updated a couple of times.
People had problems with that approach because those treatments were really validated on a narrow band of the clinical population. For one thing, the randomized clinical trials that they were based on largely excluded patients with two disorders, virtually excluded people of color, and thus were basically an artificial population. Like many clinicians, I have yet to see many patients who have only one diagnosis. I couldn't find an empirically validated treatment that had two randomized control trials that fit the population I treated, which was a combination of Axis I substance abuse and Axis II problems. And that's true for many clinicians, especially when you rule out co-morbidity.
RW: Then there is the question of using manualized treatments.
RL: Now there's a spectrum of views on manualized treatments. The most narrow view reduces the role of clinician to that of technician and allows very little deviation from the manual. The manuals that were personified in the Division 12 lists were the really rigid manuals. And then there are much more clinically sophisticated versions, like Steve Hollon's work that recognizes that therapy does have to be tailored to the needs of the person and that you do have to attend to the relationship.
So you know, it's not like a manual is always a manual.
RW: Not all manuals are created equally.
RL: So getting back to your question about why we set up the Presidential Task Force on Evidence-Based Practice. We did so because we felt we needed a much broader look at the role of evidence in practice, and we were inspired by the Institute of Medicine's approach to evidence-based medicine, which basically said that evidence-based medicine rests on a three legged stool. One leg is the research evidence, but we took a much broader approach to defining research evidence. We didn't say that only randomized clinical trials should be looked at. Certainly, they are the only way to determine causation, but they're not the only kind of research evidence. Correlational studies can help, too.
We said there's another variable, the second leg, that's ignored in the Division 12 approach, and that's the experience of the therapists. That was dismissed.
RW: Clinical judgment, clinical impressions.
RL: And clinical expertise. And it was dismissed because of the Kahneman and Tversky article about heuristics, essentially showing that clinicians could make errors. Well, guess what? Researchers make errors, too. We all make errors. Humans make errors, but that doesn't mean that there isn't data that supports the idea that there's such a thing as expertise. In fact, there is a lot of data that shows that expert clinicians behave differently than neophyte clinicians.
We said part of clinical expertise is really knowing the research literature enough to know how best to serve your patient.
RW: And then there is the patient and what they bring to the equation.
RL: Yes, the third leg of the stool is the patient because
psychotherapy is not an approach where a technician does something to a person and then they go off and essentially live with it.
psychotherapy is not an approach where a technician does something to a person and then they go off and essentially live with it. It's not like surgery. It's a collaborative process. The clinician and the patient work together. The patient has to participate. They have to bring in the material. They have to apply the techniques. Patients have preferences for how they'd like to work. They have values. Patients of different cultures have different cultural understandings of the word, of the concepts of healing.
RW: Alright, to go over my sense of this, the three legs are: one, the best research evidence on psychotherapy and assessment broadly defined, including randomized trials, the alliance, case studies and so on; two, clinician expertise including the use of the alliance and the interpersonal relationship, clinical judgment, self-reflection, understanding of culture, and so on; and three, patient characteristics, values, and context which takes into account patient motivation, support, readiness to change, preferences, culture, functioning level, presenting problem and so forth. The lists are longer but does that seems to be the gist?
RL: Yes, those are the basics. To see the details people can look at a recent article published in the American Psychologistin May-June, 2006 which focuses on evidence-based practice. We define that broadly to include all psychological practices; not simply treatment, but also assessment, consultation, prevention and a whole range of things. And we said that when psychologists practice, they really should take into account the research evidence, broadly conceived clinician judgment, and work to improve their own judgment and expertise.
RW: Including, it must be added, the importance of case studies, which was excluded in early versions of empirically-based work.
RL: Yes, that's very much a part of the research evidence. The Division 12 excluded everything except for randomized clinical trials.
RW: If medicine only included randomized clinical trial, we wouldn’t have much medicine, right?
RL: Quite correct. Certainly you have to assign relative weights to different kinds of evidence but if you were to simply follow the Division 12 approach, you'd probably have to turn away 68 percent of the people who came for your services because you wouldn't have randomized control trials to back-up an approach for them.
RW: How did all these researchers and psychotherapists from different positions work together?
RL: We tried to get people on all sides of the spectrum, drawing on the task force, to essentially debate and dialogue on a wide range of issues. I think it would be hard to find an issue that doesn't come up in our debates. Norcross, Beutler, and I brought out a book on evidence-based practice, (Evidence-Based Practices in Mental Health: Debate and Dialogue on the Fundamental Questions) which opens up the discussion.
RW: Now did the folks who were advocating for the earlier view of evidence-based therapy, stricter manualized treatments, and randomized trials, how did they participate in these task forces? Was there a meeting anywhere in the middle?
RL: Yes, they were invited and did participate, including Dave Barlow and Steve Hollon. Barlow is the one that created that Division 12 Task Force. And we had Drew Westen, John Norcross (see Norcross'
Stages of Change for Addictions video), Bruce Wampold, and people from just a broad range of perspectives.
At the very first evidence-based practice meetings, we gave everybody an opportunity to put their stuff on the table with three PowerPoint slides. No more!
At the very first evidence-based practice meetings, we gave everybody an opportunity to put their stuff on the table with three PowerPoint slides. No more!
RW: I like that; a psychologist having to limit themselves to three slides and be very concise.
RL: What is the kernel? What is the essence of what you're about? Really forcing them to think about what's most important. Then we put them into breakout groups where we mixed them up. So we had people like Carol Goodheart and David Barlow in the same group.
Now these two individuals—Carol's a well-known clinician, David's a well-known researcher—normally wouldn't attend each other's convention programs. But here they're kind of forced to listen to each other's perspective. And so Carol had to really understand why David thought that randomized clinical trials was an adequate basis for this, and then David had to understand why Carol felt hamstrung by that because so few patients would fit into those narrow criteria. And they had to then address the middle ground in between them.
They had to address the vast unaddressed part, because what we were dealing with was extreme views. And that's really what the Evidence-Based Practice Report does—it sketches out the middle.
They had to address the vast unaddressed part, because what we were dealing with was extreme views. And that's really what the Evidence-Based Practice Report does—it sketches out the middle. The report is lengthy but basically says, "When you're a clinician and you're trying to provide services in good faith to your clients, here's a good way to use the evidence and where there is no evidence, here are other things you can do." Or, "Here is the best work to date on psychotherapy research, the contributions of the psychotherapist, and the contributions of the patient."
RW: This is a real contribution to the field, instead of succumbing to the pressure to get more narrow about practice, it was opened up to every meaningful avenue for the growth and value of psychotherapy. And I’m sure you heard, but for ground floor therapists and colleagues and professors, this has been something I think people can join with, psychologists and psychotherapists of different theoretical orientations, because it’s fairly comprehensive and it’s inclusive. And it values the relationship. It values randomized trials. It values what we’ve been doing to better the lives of people, so it really is a godsend. Of course, this is not the end, but it is a testament to brilliant people putting aside their differences, and making a meaningful contribution. People really rose above the typical turf battles, this time, at least.
RL: Well, we haven't solved all the problems, but we've created a different format for the debate. I don't think anybody would, at this point in time, think of just simply, "Let's get a group of people who only agree with us, and let's just talk amongst ourselves." We've also got to get practicing clinicians in on designing these studies if they're going to be useful to them.
And clinicians like Steve Ragusea have started to create these practice research networks among themselves, networking with scientists. So he was networking with some people at Penn who were advising him. He's not a researcher. He's a very good clinician. And he and his colleagues created a practice research network.
So I think what we've done is we've populated the middle ground and taken the emphasis away from the extreme positions. You know, you had your extreme positions 10 years ago: "Only randomized control trials" vs. "I want to do long-term psychoanalysis, and I don't care if there's any evidence."
RW: Psychoanalysis, my psychoanalyst friend Lee Rather used to say, is based on the “case study method, which is part of the scientific method.” It is systematic and it is the way analysts test hypothesis in clinical practice. And the CBT folks were saying, “Let’s do a pre-test, during-test, and post-test. Let’s do the Beck Inventory, let’s control client selection.” Luborksy and Strupp, of course, did some work on researching outcomes for psychodynamic therapy in a systematic way.
RL: Right. And when I mentioned that, I was not trying to mischaracterize people, but in '95, people thought it was legitimate to stay in your camp and I don't think any more people see that as legitimate. You have to address the middle ground and continue the dialogue in a way that includes both sides of practice.
RW: Well, that’s good, because that’s what psychologists have been preaching particularly in politics. Psychologists are always out there saying, “Why can’t people and countries make peace? Why can’t they talk? Why can’t they negotiate?” You always hear psychologists saying that in the press. But if we don’t talk to each other then our methods don’t amount to much.
RL: We need to apply it to ourselves.
RW: Let’s dig a bit into something you’ve emphasized, which is the importance of clinical judgment and the clinical relationship in outcomes research.
RL: Well, I think Norcross' book (
Psychotherapy Relationships that Work: Therapist Contributions and Responsiveness to Patients, Edited by John Norcross), which is based on the Division of Psychotherapy 29th Task Force, did a great service. This preceded my presidential initiative but it was an important stepping stone, and it was after the Division 12 lists of empirically validated treatments. His book and his task force brought together—essentially assembled—all the evidence for the therapeutic relationship.
And the evidence that he assembled shows that the quality of the therapeutic relationship outweighs the influence of the model of therapy you're using. And the book went further to delineate and really look at specific evidence for different aspects of the relationship, from working alliance to empathy to some of the conditions that were described by Rogers back when he was doing research on empathy and conditional regard, and so on. It's hard to dispute that the therapeutic relationship accounts for a large percentage of the variance in therapeutic outcome, which can be viewed as part of clinician expertise. We really have to know a lot about how to build that relationship. We have to know about stages of change, the Prochaska model, and understand what stage our clients are in and tailor our interventions accordingly.
Also, there are important cultural variables. We have to become multi-culturally competent.
RW: Multiculturalism is clearly part of everything psychology does these days, and rightly so. APA considers it an important part of accreditation, and in practice and research. So psychotherapy, of course, requires attention to a client’s culture vs. one-size-fits-all therapy techniques.
RL: I don't know why our field got away with this for so long, but so much of our earlier clinical research virtually excluded people of color, and looking back on it now, I just have to scratch my head. What were they thinking? Are we not going to treat people of color? Are there not people of color who need our services? I mean, I just don't get it. But evidently, the zeitgeist of the time was that you could ignore that. Maybe the progress of civilization can be measured by the realization of the need for inclusiveness.
RW: Let’s hope we are headed in that inclusive direction for good. Thanks so much for taking the time to speak with us on these most important issues.
RL: Thank you.
