Psychotherapy Research,
Evaluation and Quality Management in the Practice of GIPT(1)
Rudolf Sponsel (GIPT), Erlangen
Joint Practice for General and Integrative Psychotherapy and Psychotherapy
Research translated by Agnes Mehl
List of Contents - Summary
Weights of the areas of life
Summary
The first part introduces the conception of the clinical-psychological
psychotherapy research according to a report of the APA (1994, see Hahlweg
1995) and gives a brief critical discussion. The second part first demonstrates
the psychotherapy evaluation as a relation model of ten digits: Pts = f
(environment, experimentee, disorder, methods, technical realization, user,
criteria, judge, evaluation method, other factors) and the traditional
psychotherapy research is criticized.
Afterwards it is shown, how psychotherapy research is seen, applied
and judged within the framework of evaluation and quality management of
the General and Integrative Psychological Psychotherapy (GIPT). Among others
the following proposition is justified:
Any reflected-differentiated and documented practice of psychotherapy
is at the same time genuine psychotherapy research. Thus any only nomothetic
oriented research is to be rejected as biased, reduced and irrelevant.
The third part introduces a practically-empirically tested and substantial
manual for a criterion-oriented therapy planning and estimation of therapy
success, which is also suitable to control intra- and interpsychical dispacements
of symptoms.
A short outline of the history of GIPT and of the concept of cures
is given including case examples and also the model of illness and the
problem of causality with respect to etiology is explained. It is shown,
that there is no scientific alternative to the general and integrative
psychotherapy. Dogmatism of schools is a professional error and according
to Mallach et. al. (1993) it is said: "If a medical professional overlooks
new methods of treatment and sticks to out-dated methods this is contrary
to duty". This of course is also true for psychotherapists.
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First Part
Current Clinical Psychological Psychotherapy Research and Concepts of Quality
Management: the APA Development Study 1994
In March 1994 the section of clinical psychology of the American Psychological
Association (APA) has given a report of the "team for promoting and spreading
psychological methods (see Hahlweg 1995) which tries to solve the problem
of quality management as follows. First three quality classes are differentiated:
(1) therapies of well verified effectiveness
(2) probably effective therapies
(3) experimental therapies
It is important to note that according to this team the evaluation can
and should be tested with respect to a specific problem. For the integrative
ideographic approach this still doesn't go far enough, but the tendency
is getting close (loc cit. table 1:277, table 2:278).
Table 1: Criteria
for empirically valid therapies: therapies of well verified effectiveness
I. At least two sound group studies carried out by different research
groups prove the
effectiveness of the therapy by at least one of
the following conditions:
A. The therapy is better than another treatment or a placebo treatment
(using pills or caring).
B. It is comparable to an already proven form of therapy in studies
of adequate statistical
power. OR
II. A large number of case studies proves the effectiveness of the therapy.
The studies
have to
A. have an experimental design
B. compare the effectiveness of the interventions
in question to another form of treatment (see I.A).
Further criteria for I and II:
III. The examined therapies have to be based on manuals of treatment.
IV. The characteristics of the respective sample have to be clearly
specified.
Table 2: Criteria
for empirically valid therapies: probably effective forms of therapy
I. Two studies prove that the therapy is more effective than a waiting
list control group.
OR
II. Two studies, which meet the criteria I, III and IV for sufficiently
proven forms of therapy in another way, but are carried out by the same
research group, or a sound study proving the effectiveness of the therapy
on the basis of these criteria.
OR
III. At least two sound studies prove the effectiveness of the therapy
but are limited in
their significance by the heterogenity of the examined
samples.
OR
IV. A smaller number of case studies meeting the criteria of well proven
forms of therapy."
Critique
There is a predominance of behavioral therapy(3)
on the part of references. To ask for an "experimental design" for the
individual case is extremely impractical and eccentric, especially as it
is not even explicit what is meant exactly. It would be much more important
to ask for a comprehensible documentation to check what really was done.
The work concept has a pragmatic orientation and doesn't seem to know critical
problems. It is positive that the research on individual cases is not misunderstood
as the starting point of a supposedly "true research", but it is accepted
as being equal.
Second Part The Combinatory
Explosion of the Variety of Variables in Reality
Description of the problem: The treatment process (counselling, therapy)
is influenced by many factors. Even if only few are differentiated, the
explosion ob combinations is obvious even with simple configurations. These
facts are the basis for Kieslern (German 1977) still valid and important
criticism of the myth of uniformity within psychotherapy research. So far
the traditional psychotherapy research was not able to draw the only correct
conclusion from this that only an ideographic evaluation concept of the
individual case could lead the way out of the dilemma. At least the following
relevant classes of variables have to be considered for a therapy result
TR:
TR
= f ( Ei, Pi, Si, Mi, Ti,
Ui, Ci, Ji, EMi, Xi
)
(1) Environments, situations,
contexts of the clients/patients E1, E2, ...
Ei ... En. En and the influences
of these environments including the two main environments: personal relations
(partnership, familiy, friends, acquaintances, neighbours) and work environment
(work and profession, position, colleagues, business partners). An other
perspective looks at the individual framework of reality and at specific
conditions.
Looking at a group of only four persons, like a family, with four basically
possible affective relations results in more than for billion possible
combinations (Sponsel, 1995).
(2) Persons having problems,
disorders, illnesses - P1, P2, ... Pi
... Pn, e.g. individuals (children, youngsters, adults, old
people) couples, families, groups, teams, organisations (systems) with
their specific personality, genetic disposition and current life situation
including the specific individual background.
(3) Problems, disorders, illnesses
S1 , S2 , ... Si ... Sn, also
symptoms,
syndromes, illnesses, disorders, troubles and handicaps.
(4) Applied methods M1,
M2, ... Mi ... Mn to solve the problems,
disorders and illnesses e.g. autogenic training, prescription of sports
and play, practising the progressive muscle relaxation for disorders of
the type "lack of relaxation". On the concepts of the methods within the
GIPT see Sponsel (1995, 103): "Method indicates the fundamental path to
seek for a goal."
(5) Technical realization
of the methods T1 , T2 , ... Ti ... Tn.
Technique in GIPT means the specific form of a methodical realization (organization,
presentation, the way and the application mode of the method). The technical
realization often is not sufficiently recognized - especially among therapists
who are critical of techniques. Often, however, the wrapping and the "how"
are very important.
(6) Users (psychotherapists,
cousellors) of methods U1, U2, ... Ui
... Un, , e.g. laypersons, students, candidates, experts with
different therapy trainings.
(7) Criteria C1, C2,
... Ci ... Cn, of changes, success or failure
of therapy, e.g. measures of symptoms (scaling of the severity of the symptoms,
e.g. according to the quality of symptoms, intensity, frequence, degree
of harm), global health measures (like the trias by Freud, satisfaction
within the norm, well being - not valid for manic processes or for a obsessive-compulsive
isolation of symptoms - satisfaction in life within the norm), measures
of criteria e.g. reducing sick-leave days, goal <partner found> or <separation
managed> or <dis-loving successful>, reducing the use of pills by half,
no stationary treatment for x time units, symptoms improved, <attitude
E changed>.
Important addition: This is the place for the intra- and interpsychic
problem of displacement of symptoms. It is not enough to only find a reduction
of symptoms, although this often is a necessary and criterion-valid reflection
of the cures. On the problem of measuring in the brief and hazy within
the ideographic see Sponsel (in preparation).
(8) Sources of judges J1,
J2, ... Ji ... Jn, , e.g. self informations
of clients, reports of relatives or colleagues, impressions of therapists,
impressions of independent judges on the basis of data.
(9) Methods of evaluation
EMT1, EMT2, ... EMTi ... EMTn
of the results of judgement, e.g. how good and reliable are the applied
methods (objectivity, validity, reliability, stability, fairness, usefulness).
T=type. At least three levels have to be distinguished for the evaluation:
(T=1) individual case, (T=2) forming a group from individual cases (group
study), (T=3) forming meta-analysis from group studies (quality and quantity).
On the problem of evaluation especially qualitataive evaluation see Sponsel
(in preparation).
(10) Other influencies Xi
Quality management and assessment of psychotherapy results according
to this is a ten digit relation: TR = f (E_nvironment, P_erson, S_ymptoms,
M_ethod, T_echnique, U_ser, C_riteria, J_udges, E_valuation M_ethod,
X_rest and rescue category).
For any disorder Si there is a client/patient Pi
having it, living in a specific environment Ei .
A therapy method Mi is applied by a user Ui
in a certain technical realization Ti with this or that
result according to the criteria Ci as seen by the judges
Ji , ascertained by the evaluation method EMi .
It can be seen easily that the combinations of variables exceed the
trillions without problem. To be able to research in the traditional way
one has to simplify to the extreme and to abstract and thus ends up with
the myth of uniformity by Kiesler and thus with very questionable results.
On the other side the attempt of Kiesler to handle the astronomic combinations
of variables in a grid model (1969) also has to fail, as Grawe (1988, 2)
points out.
It is asking too much of the traditional research on psychotherapy
and so far it cannot solve the problem of the individual case in a way
to satisfy the practicioner. The main reasons are:
(1) most researchers have little or no therapeutic experience and don't
know what is really going on; (2) most of them have a questionable education
in statistics-methodology and know little ideographically, because most
courses have no concept for this; (3) it lacks creative ideas. This, however,
doesn't prevent many "scientists" to feel superiour to ideagraphically
experienced practicioners. In fact all psychotherapists conceptualizing
and using therapy in a differentiating-reflecting (metatherapeutic) way
are genuine researchers of psychotherapy. This can be controlled the better,
the better they document their therapeutic work. The elementary problem
of any research not starting off ideographically with the individual case
is the basic "aporie" of the transfer of the results, i.e. when and under
which conditions may a conclusion be drawn from the evaluation to the application
in a new case and vice versa when may a conclusion be drawn from an individual
case result to a general application. According to the strictly traditional
theory of science both cases - deductive and inductive - are logically
not proven arguments by analogy. Already this consideration shows, that
the traditional theory of science generally is not helpful. On the critique
of the traditional theory of science see Sponsel (1995, 328-352), especially
on the liberal concept of a theory of science of GIPT (loc cit. 335).
The extreme astronomical possibilities, which lie in only one psychotherapy,
are also the scientific reason why the traditional schools of therapy with
their narrow dogmatic concepts represent rather a confession than a profession
and don½t stand up to the variability and complexity of realtity.
Therefore there exists no scientific alternative to the general and integrative
psychotherapy. Dogmatism of schools is a professional error and Mallach
(1993,2) says on this:
"If a medical professional overlooks new methods of treatment and
sticks to out-dated methods this is contrary to duty (BGH*
NJW 1978 587, OLG Bamberg VerR 1977 436)." This of course is also true
for psychotherapists.
*Top court (in Germany)
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Third PartTherapy
Evaluation in the GIPTDigression: Brief
History of the "GDEIS"(4)
Movement(5)
Before Freud almost all of psychiatry and the included psychotherapy
of the time was
G_eneral, D_ifferential, E_clectical, I_ntegrative,
S_chools
and methodes integrating ("GDEIS") - ignored(6)
and suppressed by Freud and his successors. This is documented by many
psychological-psychopathological journals(7)
since 1780. Then the empirical psychology started to develop. The first
measures on after-sensations were reported by Nikolaus Tetus (around 1770).
And C.C.E. Schmidt(9) recognized already
in 1791 - almost 200 years before a systematic movement - that the human
body is e.g. an organized and a self organizing being. And already in 1751
Johann Christian Bolten, physician in Halle realized that the basis
of any psychotherapy is a sound knowledge of psychology. The first large
and systematic publication on general and integrative psychotherapy
was written by Johann Christian Reil in 1803 (see Ernest
Harms (1960). American Psychiatric Association Journal (66,
1037-1039)
J.A.C. Heinroth (1773-1843), who in 1811 got the first chair of psychic
therapy(10), recognized in his textbook
of psychic disorders the great significance of heuristics for skilled treatment.
According to Heinroth therapy is a heuristic "business". Even Wilhelm
Griesinger (1817-1868), who is said to be the founder of scientific
psychiatry, wrote in "Pathologie und Therapie der psychischen Krankheiten"
(pathology and therapy of psychic illnesses) in 1861 (§205, p. 471):
"Zunächst auch von der Thatsache des empirisch constatirten Erfolges
ist auszugehen, indem für die psychische und somatische Heilmethode
eine absolut gleiche Berechtigung in Anspruch genemmen wir(first one has
to start off with the fact of empirically proven success by making psychic
and somatic cures absolutely equally available)". Griessinger didn't shy
away from using the term Eclecticism and advocated an "ecclectische Concession
beider Partheien" (eclectic concession on both sides) (p.471), like before
Leupoldt in Erlangen in his textbook from 1837 (p.27). In 1897 Leopold
Löwenfeld, who in the 1870s spent a few years in the USA, published
his textbook on the complete psychotherapy. He was followed by no one less
than Hugo Münsterberg in 1909 with his Psychotherapy and in 1914 with
a corresponding section in "Grundzüge der Psychotechnik" (essential
features of psychotechnique). Also Dornblüth, founder of the clinical
dictionary, today known as Pschyrembel, wrote a general psychotherapy in
1911.
In 1936 the work by Saul Rosenzweig `Some Implicit Common Factors` was
published including the famous statement: "At last the Dodi said, 'Everybody
has won, and all must have prices'". Already in 1940(11)
there were first efforts to bring different schools of therapy round the
conference table (for reference see a reader by Sponsel 1995, p.587) including
Carl Rogers - completely unknown at the time, today well-known - and Saul
Rosenzweig, a psychotherapy researcher being close to psychoanalysis, who
was snubbed so nastily and unadequately by Freud.
Still much further back to the year 1910 reaches the branch of psychosynthesis(12),
which Roberto Assagnoli first outlines in his critical dissertation on
Freud.
early approaches (in the 20th century). In 1950 the famous publication
Personality and Psychotherapy: An Analysis in Terms of Learning, Thinking
and Culture by Dollard and Miller comes out. Also around this time Thorne
starts publishing.
J.D. Frank publishes his pioneering book on general curing factors
from schamanism to modern psychotherapy in 1961 (German 1981).
Lazarus says to have started developing the technical eclecticism
and the multimodal therapy around 1967.
From the humanist psychotherapy Hilarion Petzold develops his
large and still continuing work in Germany starting in the 70s: from 1975
the magazine "Integrative Therapie" comes out - the same year Bastine publishes
an important article in Psychologie Heute; in 1993 his main publication
in three volumes comes out.
In 1967 the book by Neisser comes out indicating the famous cognitive
swing, which in psychotherapeutic circles had been already anticipated
by Ellis in 1956 (published in 1962). In the same year Systems of psychotherapy:
A comparative study by Ford and Urban comes out. In 1977 the book by P.
Wachtel "Psychoanalyse und Verhaltenstherapie. Ein Plädoyer für
ihre Integration (psychoanalysis and behavioural therapy: a summation to
favour their integration) comes out.
A particular year became 1979, when Renaud van Quekelberghe presents
the first modern and fundamental publication on general and integrative
psychotherapy (written in 1977): "Systematik der Psychotherapie (systematology
of psychotherapy) forming the basis for the qualification of the schools
and methods integrating clinical psychologist BDP(13)
The concept of schools and methods integrating psychotherapy plays and
important and central role(14) in the certification
of clinical psychologists by the professional association.
In 1980 (German 1982) appears Garfield`s psychotherapy - an eclectic
approach.
From this all goes very rapidly and in the 70s and 80s the first international
"GDEIS" organizations develop. The International Academy of Eclectic
Psychotherapists (IAEP)(15) , which
e.g. Ellis is member of, was founded in 1982 and organizes trainings and
congresses (also on an international scale) and publishes a magazine (JIEP).
The Society for Exploration of Psychotherapy Integration (SEPI)
was founded in 1983 and since then trainings are carried out regularly
in many countries around the world and are documented in the magazine "Journal
of Psychotherapy Integration". At the moment it has around 900 members,
among them also many famous psychotherapists and psychotherapy researchers
(e.g. Lazarus, Beck, Mahoney, Wachtel, Garfiled). The SEPI sees
itself as institution to promote the contact between schools and the school
integrating development. Homepage
SEPI
In association with SEPI and the Academy many articles and books on
general, differential, eclectic, integrative and schools and methods integrating
psychotherapy come out (e.g. Norcross 1986, 1987; Norcross & Garfield
1992; Stricker & Gold 1993), but they all don't really reach up
to the fundamental and general approach by van Quekelberghe.
On November,11.,1993 the DGGK (Deutsche Gesellschaft für Gestalttherapie
und Kreativitätsförderung, German association for integrative
Gestalttherapy and promoting creativity) was renamed after 20 years to
DGIK (Deutsche gesellschaft für Integrative Therapie, Gestalttherapie
und Kreativitätsförderung, German association for integrative
therapy, Gestalttherapy and promoting creativity) (around 700 members).
Numerous publications on the theory and practice of psychotherapy have
been published not only with the associated publishing company, Jungfermann
Verlag.
Since 1992 the chair of Grawe in Bern provides on a general training
of psychotherapy, which now is started once a year. In his infamous book
"Psychotherapie im Wandel" (changing psychotherapy)(16)
it says on page 787:
"We are convinced, that it is possible, even today, to realize
an approximation towards such a general psychotherapy within trainings
of psychotherapy and the practice of psychotherapy. We don't have to wait
for a better formulated or better empirically tested concept."
(emphasizing
by R. Sponsel).
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In the meantime two originally behavioural therapeutic training institutes
(Munich and Bamberg) have been renamed as CIP (center of integrative therapy)
and now train also "integratively", but with a behavioral therapeutic main
focus and corresponding restriction.
In 1992, after 8 years of work, the Swiss group Blaser, Heim, Ringer
and Thommen presented an eclectic-integrative publication on effective
short-term therapy, which was developed at the psychiatric university hospital
of Bern. There also trainings are taking place.
In Freiburg (Germany) the colleague Schramm trains IPT under Prof. Berger
(Klerman & Weissman) and Berger also trains integrative, inclusive
psychoanalysis and behavioural therapy. The medical profession generally
tends to get trained very much integratively and get double qualifications
(psychoanalysis and behavioural therapy).
I investigated and documented around 800 publications (of an estimated
1000) in my book on general and integrative therapy. And already in 1984
I carried out an extensive control study on the success of intergrative
psychotherapy on a sample of N=1091.
1. The proceeding of the GIPT. It is summarized on the back of our application
foms for psychotherapy - comprehensible for agencies bearing financial
responsibility and patients.
I)
Scientific basis of the GIPT For abbreviations
and quotations see Sponsel 1995 (17)
Historically the general and integrative psychotherapy is based on the
psychological, psychiatric and psychotherapeutic works by Johann Christian
Reil (1803, 1805, 1808, 1812) and later for example on the works by Otto
Binswanger (1896), Leopold Löwenfeld (1897), Otto Dornblüth (1911)
and Hugo Münsterberg (1909, 1914), (Sponsel 1997).
The newer development of the general and integrative psychological
psychotherapy (GIPT) scientifically is based on the fundamental principles
of psychology, the processing by the international schools and methods
integrating development of psychotherapy (18)
and evaluation (Van Quekelberghe 1979 (19),
Garfield German 1982, Petzold 1993, the DGIK (since 1993), EAG (since 1989)
IAEP (since 1982, SEPI (since 1983), SEPI Germany (since 1995), Glatzel
(1995) and Grawe et.al. (1994), Grawe 1995, Hummitzsch 1995, Sponsel 1995
etc. and the practical work proven for decades by the "schulen- und
methoden übergreifenden Klinischen Psychologischen PsychotherapeutInnen
des Berufsverbandes Deutscher Psychologinnen und Psycholgen ("KLIPS") (schools
and methods integrating clinical psychological psychotherapists (qualification
by the association of German psychologists) like it is described e.g. by
Blaser et.el. 1992, Rahm et.al. 1992 or Sponsel 1995.
II)
What is the working method of the GIPT like?
1) Working relation and assessment. First it is part of
probatory sessions to find out whether a successful working relation can
be expected, whether the patient has got trust in the competence of the
GIPT therapist and the therapist feels qualified for the problem und thinks
to be successful. From the beginning the eco-social environment of the
patient is taken into consideration and possible inclusions are checked.
2) Case history, specific analysis of symptoms,
causal (ethiological) diagnosis. (a) A detailed and comprehensive general
case history (AAA) justifies that no relevant factors for the disorder
are neglected, the optimal treatment is choosen (e.g. heart neurosis;
Sponsel 1995 p. 461-463) and the positive ressources are included.
(b) Afterwards it is soundly and specifically examined, how the disorders
could have been developed, triggered, caused and maintained. (c)
The causal development has to be examined better and more profoundly in
cases, where a therapy without causal understanding doesn't appear to be
successful.
3) Plan of treatment. On the basis of etiological
knowledge a heursitic plan (heuristic being the science of problem
solving) of treatment is developed according to curing experience, thinking
and intuition, how this disorder(s) or illness should and can be treated
under these conditions for this patient with this eco-social environment
in a way that essential improvement, curing or a better coping is probable.
The corresponding cures, methods and techniques are named, if they are
familiar, or described. If methods are imported from schools of therapy,
it is explained, how they are adapted.
4) Control and evaluation. The plan of treatment is documented
in written form for control and evaluation purposes and is supplemented,
modified and adapted for the current situation by records.
5) Quality management. The GIPT therapist is qualified
as clinical psychologist - in the school and methods integrating way -
by the association of German psychologists (BDP) and is subject to the
professional ethical obligations and the obligations for supervision and
training by the professional association.
In the GIPT the same ideas are valid on therapy
evaluation as are developed by Kanfer, Reinecker & Schmelzer (1991)
in "Selbstmanagementtherapie" (selfmanagementntherapy) (phase 6 and 7).
Diagnostics and therapy according to ourmideas are mutually dependent and
permanent. Thus diagnostics is part of any therapy and has to take place
constantly.
III) The General and integrative (GIPT)bio-psycho-social
model of illness
Fig.
The general model is based on a model of system disorders distinguishing
the following phases of development: 1) Causes, conditions and evoking
factors of the disorder. 2) The valuation of the disorder as illness. For
the character of an illness reasonably an - important - disorder of function
is defined (according to Gustav von Bergmann (1878-1955). 3) Different
consequences (local, central, general, specific) of the disorder. 4) Raising
and processing of information on the disorder and 5) The recovering procedures:
the conflict between the forces of the disorder and the cure. Disorders
can be exogenous (outside of the system) and endegenous (inside the system).
Disorders generally have causes, which are dealt with in etiology within
a general theory of illness . If a disorder, as mostly, is developed during
time, this process is called pathology. Often the concept of symptom is
not clear, as it may have a threefold meaning according to the model theory:
1) it is a sign of the disorder (e.g. certain antigenes in the body; anxiety);
2) it is a sign of the spontanous reaction to the disorder (e.g. certain
anti-bodies against the antigenes; avoiding); 3) it is a sign of the recovering
procedure, thus expressing the "struggle" between illness and curing processes
(e.g. high temperature; conflict of ambivalence between avoiding and confronting).
The problem of causality
The problem of causes is difficult according to the theory of science
for two principal and one avoidable reason: (1) Strictly speaking there
is only one tree with many branches according to the concept of causality.
Every identified cause can be traced back to other causes or at least can
be thought to be traced back to another. Which of these many causes can
be choosen to be the specific one? In reality it is mostly a complex of
causes, a network of conditions. (2) One has to differentiate between conditions
(framework or side conditions), occasions or triggers, and side and associating
effects, which often ist very difficult. (3) The psychic events can be
seen from several perspectives: e.g. physical, biological, chemical, physiological,
neurological, internistical, psycho-pharmacological, immunological, cybernetic,
psychological, socio-economical, social psychological, social-permissible
in law and communicative. Additionally, in the metapher of a computer the
hardware being physical and the software being psychic, both are multiply
joined and interrelated for the realization of the operating system of
man. It is not necessarily observable whether the bio-cybernetic events
of the body represent the "hardware" or the "software". Thus in many articles
and books three levels are confused: a) perspective (e.g. physical, chemical,
biological, medical, psychological, social), b) representation of hardware
or software, c) causes, side and associated effects or results. Independent
of the problems, the conceptual idea of one or more causes (trees or braches)
naturally is meaningful and reasonable. The tendency of some systematists
and popular constructionists to play down the problem of causes or even
declair it for completely superfluous, cannot be shared nor accepted by
the general and integrative psychotherapy.
2.
Developing the concept of the cure and especially the
criterion-valid cure within the GIPT
Microconcepts on the process of therapy lead to the basic concept of
cures. By a cure we mean facts, the occuring of which potentielly. i.e.
relative to specific conditions has a positive, negative, neutral or ambivalent
effect completely or partially with a certain probability.
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Basic definitions
These facts that cure potentially, we call cure
(curative factor); the process
to establish or evoke them, are called methods
and the specific way, how
it is done, is called technique. Different methods
are summarized in the concept of procedures. (20)
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Autogenic Training e.g. thus is a method to evoke the cure (curative
factor) of relaxation. The specific application and wrapping: individually
or in a group, in sections or in one stretch, lying or in cabman's position,
are questions of the technique. The different methods of relaxation form
the class of relaxation procedures e.g. autogenic training; progressive
muscle relaxation; functional relaxation; hypnosis; meditation; natural
methods like sports, playing, arts and culture; sleeping, lazing about
and
relaxing. Well known and effective cures (curative factors) naturally cannot
belong to a school of therapy, even if they have been found or invented
by it, but they are part of the general theory of cures and belong to everyone.
Positive cures improve, negative ones worsen a state of disorder or
illness, neutral ones have no and ambivalent ones have positive as well
as negative effects. Important general cures are for example activity,
giving up (letting go), consciousness, thinking, working through, attitude,
being aware / experiencing, feeling, sensing, assigning or giving energy
to ..., experience, knowing (ability, competence), cognitive schemes (concepts),
guiding, learning, confronting, doing, overcoming, avoiding, preparing,
rating/judging - primarily, rating/judging.
Cures can also be organized according to the perspective of important
life themes, which at the same time is creating a therapy relevant checklist
for case histories, e.g.: competition, rivalry, treating competitors, performance,
effort, knowing, ability, competence, learning, talent, aptitude; coping,
standing, tolerating, coping with, accepting; counting, position, rank,
status; having e.g. work, flat, money, social security, partner, lover;
goals in life, joie de vivre, respect, recognition; communication, clarity,
sincerety, expressiveness; interests, inclination, preferences, dislikes;
relation, distance, closeness, intimity, trust, bonding, love, hatred,
partner, lover, relatives, aquaintances, contact; fighting, victory, defeat,
winning, loosing, confronting, escaping; asserting, achieving, arguing,
insisting; relaxation, calm, recreation, sleep; balancing/compensation:
leisure, play, free time, pleasure; health, intactness.
Theoretically there is an infinite number of cures; those being practically
relevant can be reduced to a few dozens (Survey see Sponsel 1995, 193-200).
It looks like there are completely elementary and no further reducable
cures, which we call atomic cures because they cannot be further taken
apart on the level of psychic experiencing and consciousness. Experiencing_feeling_sensing
doesn't seem to be taken further apart, whereas the process of remembering
at least can be supported by different activities and thus represents rather
a molecular or more complex cure. At the moment we cannot estimate the
significance of the difference. However we want to warn to overestimate
these differences. Learning and guiding definitely are no atomic, but very
general cures, programs or because of their very general importance something
like meta-cures (e.g. APLS in Sponsel 1995, 293). The following remarks,
however, we think of being very important. It could be true, that these
ideas contain the solution to some fundamental problems of therapy research.
The most important schools of psychotherapy and main classes of cures
can be illustrated in a tree of psychotherapy:
Tree of psychotherapy
The class of cures (curative factors) experiencing_feeling_sensing
e.g. play an important part with the client-centered psychotherapy, with
focusing,
with body therapies, with Gestalt and with all relaxation therapies. The
cure (curative factor) relaxing thus is a very important species of this
class of cures (curative factors). Alexithmias, lack of orientation, psychosomatic
masks of symptoms, stress and burn-out symptoms very often have to do with
disturbences of experiencing_feeling-sensing. It is hard to overestimate
the class of cures (curative factors) of experiencing_feeling_sensing;
by the way it also supplies the psychological basis of the important class
of cures (curative factors) of judging.
Understanding, consciousness and catharsis are the main
cures (main curative factors) of psychoanalysis, but also of Gestalt and
client-centered psychotherapy.
Learning and behaviour are the fundamental classes of behavioural
therapeutic cures (curative factors).
Working through and clarifying are important species of
the class of cures (curative factors)of communication playing a central
part in all psychotherapies.
Rules - guiding, shaping and changing relationships - are important
cures (curative factors) of interpersonal therapies, the transaction analysis,
the system, strategic and communication therapy, especially of the application
in group and familiy therapy.
Confronting are species of various classes of cures (curative
factors), especially of doing which play a central part in behavioural
and system therapy.
Guiding probably is the most important cure (curative factor)
of all. It plays an obvious part treating compulsion, impulse neurosis,
addictions and dependencies, avoiding behaviour and all the disorders of
the type self-control on one side and overcoming passivity, lack of interest
and lethargy on the other.
Criterion valid cures. Depending
on the goals of therapy respectively the classes of goals looked at, a
cure can become a necessary, adequate or necessary or adequate (equivalent)
cure. Cures having such qualities in relation to classes of therapeutic
goals, we call criterion-valid cures. Thus they are criterion for evaluation.
This is of more importance, as thus the evaluation of a method is determined
or at least very much delimited.
Confronting definitely is a necessary cure for all disorders
and problems of the type avoiding, getting out of something, shirking,
circumventing unpleasant matters, thus it is necessary for the evaluation
of all phobias.
Learning and exercising are criterion-vald cures for all
disorders and problems of the type lack of ability and competence
assuming a certain level of intelligence.
The abilities experiencing_feeling_sensing and pay attention
are probably necessary and adequate cures to avoid or reduce all psychically
based disorders and problems of the type expecting too much and stress,
but also to recognize values, wishes, goals.
Abreacting (catharsis) is probably a necessary cure for all disorders
and problems of the type "affective accumulation". In order not to produce
such an affective accumulation again and again, further considerations
are necessary to prevent such an affective accumulation to happen.
I think, that the research of criterion valid cures in relation with
certain classes of disorders, problems and thus therapeutic goals will
help to bring the psychotherapy research much further.
Axiom of cures XV. Within the GIPT
the significance of cures is put down in the axiom XV (Sponsel 1995, 140):
Preliminary remark: This axiom is very radical, but represents in its radicalism
the extreme complexity, difficulty and relativity of reality. And it represents
the real experiences of any therapists and patients. It also has its good
sides: it prevents from inadmissible, simplifying and wrong generalizations
and repectively questionable schemes of diagnosis and therapy: it keeps
awake, open, critical and makes us flexible. The idea of the relativity
of all cures is an old one, basically it is found with Hippokrates, with
Moritz (1783-1793) and with the early history of psychotherapy of Reil
(1803; Sponsel 1997). Also in recent years this idea has been taken up
several times: Wyss (1982, 87f) has introduced explicitely a "general principle
of relativity" in his anthropological-integrative psychotherapy, even if
it is not as specifically differentiated as ours. The idea of a relativity
of cures can be found with many psychotherapists and researchers, the double
character came up again only recently with Kriz (1994, 236).
(1) Principle of the double character: A curing effect can derive from
the presence or absence (negation) of a cure or from a quantum of it.
(2) Fundamental relativity of effects: cures and quantities of it are
only potential cures and principally can have four effects: positive, negative,
neutral, ambivalent, i.e. positive as well as negative.
(3) Principle of individual relativity: whether a cure or a quantum
of it is effective as such, can vary from individual to individual.
(4) Principle of situative relativity: whether a cure or a quatum of
it is effective for one individual, can depend a lot on the situation,
i.e. one and the same cure or a quantum of it, can have positive effects
in one situation, negative ones in another, no effects or ambivalent ones
in a third.
From A-XV, (1) to (4) follows a strict checking of the individual case
as well with respect to the individual person as to the respective situation.
This axiom includes lots of potential professional errors (Sponsel 1997).
3.
Digression: On the history of the concept of cures (concept
of curative effects)
In the early psychiatriy and history of psychotherapy research of the
19th century the term and concept of psychic cures (curative factors) were
very common (Sponsel 1977). Even proper monopraghs came out on the issue:
Thus Dr. F.G. Bräunlich (? - 1875), director of the private hospital
Wackerbarthsruhe near Dresden, published a book of 352 paragraphs on 240
pages with the significant title "Psychische Heilmittellehre für Ärzte
und Psychologen" (Psychic theory of cures for medicals and psychologists).
He starts his book in the first chapter with the subtitle "Geschichte dre
psychischen Heilmittel" (history of psychic cures), which is subdivided
as follows: first period until 600 B.C. (21),
second period until Christ, thirs perioad until the Reformation and the
fourth period until present times. Still earlier is the work by Schneider,
P.J. (1824)(22).
A complete history was provided by Friedreich (1830). One of the first
large and fundamental works still dates back before BrŠunlich and was published
by Johann Christian Reil (1759-1813),the father of the general and integrative
psychiatry (23) and psychological psychotherapy.
In his main publication (Rhapsodien...§3) he developed a general
theory of cures appearing quite modern (chemical, physical, psychic), which
then anticipated three fundamental principles:
(1) the only potential nature of all cures (curative factors),
(2) the potentially infinite variety of cures (curative factors),
(3) the ideographic principle of relativity (Reil 1803; Löwenfeld
1897, Wyss 1982; Sponsel 1995). Reil (24)
knew clearly already in 1803, that all materials can be looked at from
several perspectives for different purposes, even have to, and that the
curative perspective is only one of them. As this cognition is of greatest
significance for practical psychotherapy I want to present the two main
propositions here again:
(1) Almost all matters can be seen from acurative perspective, but naturally
also from other perspectives (first main proposition).
(2.1) All cures (curative factors) are only potential cures (curative
factors).
(2.2) There is a potentially infinite varieta of cures (curative factors).
(2.3) The ideographic principle of relativity, i.e. whether a matter
or material works as cure (curative factor) depends completely on the framework
of reality and of the situation, on aims and purposes, abilities and possibilities
of all who are engaged in the therapeutic process.
We express this extraordinarily significant fact in the general emblem
/ logo of psychological cures (curative factors):
The black and white symbolism expresses, that the function as well as its
opposite (25) may have the effect of cures
(curative factors). The switching image in the form of an arrow expresses
that the cures (curative factors) may work completely differently depending
on the case and the situation.
Only with the development of the so-called "modern" psychotherapy and
the psychoanalysis, the valuable term of cures disappeared, to reappear
some 75 years later as curative factor respectively effecting factor in
the newer psychotherapy research (26). The
reception of the history of psychotherapy is partly extremely biased, superficial
and often wrong, unfortunately even within the academic clinical psychtherapeutic
literature. Although I generally very much appreciate the SEPI authors,
the title of the book by Freedheim (1992, Ed.) - History of Psychotherapy
- starting only with Freud seems rather astonishing; a better title would
have been History of Psychotherapy in the 20th Century.
4.
Practical Examples for a Better Understanding of
the Idea of Cures
Let's start with a classical example in various ways (history
case no. 1): Describing flooding experiences of Goethe climbing the summit
of a cathedral tower (Link
"Straßburger Münster") to overcome his fear of heights (Quotation
from Goethe 1770, from Gerlach, H.E. et.al. 1966, p.49p). As we can see
here, Goethe like many others discovered for himself the cure (curative
factor) of confronting, standing and training, which today is called confronting,
flooding and exposing.
And some 150 years later we read with Ferenczi (2,1984, vol.II, 1927,
orig. 1919, p.59-60):
Freud in a supervision
Ferenczis
for confrontation therapy
"In a couple of cases of anxiety hysteria and hysteric impotence I
made the experience, that the analysis went smoothly up to a certain point;
the patients were completely understanding, but the therapeutic success
has not yet been coming... With this problem a orally given advise by Professor
Freud helped me. He explained to me, that the anxiety hysterics have to
be asked after a certain period of time to leave the phobically secure
attitude and try just what they are most afraid of. Such advices the physician
can justify to himself as well as to the patient as any such trial will
bring out fresh, still untouched psychoanalytic material, which without
this rousing would have been gained only much later or not at all. I followed
the advise of my teacher and can only say the best about the result. The
curing of many patients really went in phases of improvement by rousing."
|
Today it is not difficult to recognize how the anxiety hysterics of Ferenczi
really were cured. And you may wonder like me, why such knowledge didn't
result in changing the fundamental psychoanalytic rule.
After all most psychic cures (curative factors) are generally known
and belong to the history of civilization of everyday life: Let's look
at another case: History case no. 3
"We, three friends from high school, went to university to study natural
sciences. We started to integrate the infinite facts of chemestry, botany
etc. in our store of knowledge and thus developed the basis for independent
working. While two of us got along, the third started to get deeper into
a sad mood finally leading to a deep melancholia and tried to commit suicide
a few times. Already at grammar school our friend had a particular interest
in history and liked written papers about causes and effects of differen
historical events the most. His melancholia could only be cured as we,
his friends, used tender strictness to take him to lectures of jurisprudence.
After a few such lectures his mood improved constantly until he was completely
healthy again. After this he enroled with the faculty of jurisprudence,
finished his studies extraordinarily successfully and stayed normal throughout
his life..."
Portrait: Iwan P. Pawlow (left), brother Dimitri (right)
|
The reporter is a well-known personality of the theory of cures, being
Pawlow (1849-1936) (27), getting the nobel
prize in 1904. It is remarkable with this case that the etiological concept
of a reactive melancholia is given and that the complete curing takes place
without any therapeutic help. It may be asked at this point, what Freud
or Rogers could have helped?
What are the cures (curative factors) here? Obviously a drastic directive
treatment by the friends opposing the parental directive and supporting
professional self-realization. The significance of this was already known
by Reil. In the "Magazin für psychische Heilkunde (journal of psychic
theory of cures) edited by Reil (portrait
of Reil) and the philosopher Kayßler in 1805, Reil develops in
his only essay "Medicin und Pädagogik" (medicine and pedagogics) the
concept of self-development by Jung and the humanist concept of self-realization:
"... education cannot be "co-curing", but only reason for self-realization
of what already is given by the predisposition" (p.418). And on p.
422: "The true method of educating and teaching is to activate and bring
to life all the inner of a person."
Belief, illusion (28) and trust e.g.
are important general psychic cures (curative factors) and the fundament
of the placebo-effect being so important for the theory of cures. The following
example taken from real life demonstrates impressively how Reil's brillant
idea of a theatrical therapy could be used.
Ellenberger reports (German 1973, vol. 2, p. 889): History
case no. 4
"Carl Gustav fainted for a while, after a schoolfriend had thrown him
backwards on the floor and pretended to be unconscious for longer to frighten
he guilty person. From then on he fainted whenever he didn't like to go
to school or do his homework. For six months he avoided school, roamed
the surroundings and indulged in his daydreams. The medicals were faced
with a mystery; one talked of epilepsy. Then one day Carl Gustav heard
how his father mentioned his worries about the future of his son when talking
to a visiting friend. Suddenly the boy realized that life was a serious
matter and that he has to prepare to make a living. From this day he tried
to suppress his fainting fits and started to do his school work. This episode
shows how a childhood neurosis can start, but also how it can be cured
spontanously as opposed to the case of Andre Gilles who's childhood was
overshadowde by a similar neurosis."
|
Carl Gustav had a traumatic experience being the cause to develop a neurotic
behaviour, here fainting fits with a secondary gain from illness. Admonitions
didn't help. Then he heard incidentially the serious worries of his father.
What are the psychic cures (curative factors) here? That it happened incidentially,
the consciousness that the father didn't know he was listening, made him
realize for the first time that his father was having serious worries.
All of a sudden (29) he gets an understanding of the seriousness
of his situation and it comes to a sudden change of attitude leading to
a changed positive and constructive school behaviour.
The important cure (curative factor) of the period of Janet (1859 -
1947), Breuer and Freud around the turn of the last century was called
catharsis. If it succeeds to make repressed traumas conscious again thus
removing dissociations of the emotion and the cognitive matter according
to the psychoanalytic hypothesis, we don't believe it so generally and
think it is true only sometimes. Combination
theory of cures and methods
Example: Working through of the childhood.
Let's assume relatively independent methods i.e. those in which the
sequence doesn't matter. Given e.g. the segment of therapy "working through
the childhood" then it includes different standard treatings, like the
following: (1) experiences and relation with the mother, (2) experiences
and relation with the father, (3) experiences and relations with sisters
and brothers, (4) significant experiences, (5) psychical working over these
experiences, (6) relations today, (7) possible therapeutic goals with respect
to the cognitive affective scheme of childhood. Spontanuously most will
aggree that the segmental parts (1) to (4) can be organized quite independently,
wheras for (7) it would be good to know (1) to (6) already.
The sequence being important, which definitely often is true in psychotherapy,
the possibilities can be calculated according to a simple permutation formula
N = faculty (n) with n being the number of combinating segments or methods.
For n=10 results N= 4.037.932, thus around four millions. The sequence
not mattering there is a simplified formula for the possibilities of combinations
2n-1. With 10 cures or combining methods result still 210-1
= 1024-1=1023 integration tasks, 100 different methods demand around
1267 650 000 000 000 000 000 000 000 000 integrations
(!) thus this cannot be the way.
5.
From the Research on GIPT Therapy
5.1
Construction and Description of Different Specific and
Gobal Measures of Criteria.
CST system. Between 1980 and 1985 I developed and empirically-practically
evaluated a number of methods being summed up in the term CST-system-diagnosis.
Aims & background. The method should be suitable for a better understanding
of human beings, for therapy planning and particularly to control the success
of psychotherapy (analysis of the existential orientation) in the established
private practice (quick, simple, tough).
test theory: criterion oriented, i.e. all methods can be interpreted
with regard to content and meaning even without statistical norms. For
all methods - exception so far: family image scale (FBS) - norms on percent
rank were drawn up usually for three comparing groups (cases, norm group,
ideal group of those being relatively healthy and satisfied). For numerous
single case studies a special measurement of reliability was developed
not having the faults and weak points of the correlation coefficient (Sponsel
1994, I, 24-33). For all metods exists a Computer evaluation and scientific
service. At the moment 6000 tests are included. The tests 01 to 08 are
described and documented in the CST-system-handbook (2 vol., around 1400
pages). For the FBS scale there exists a manual. Methods 10 and 11 are
only available through the evaluation service so far.
01 Statistical Header Card
It serves the research intending to study e.g. the character structure
of all eldest sisters woith secondary school certificate, the life satisfaction
of unemployed, the personality structure and first diagnosis of therapy
drop-outs or of asthmatics then the statistical Header Card allows the
specific search by computer coding.
02
CST - character-structure-test (according to Fritz Riemann)
The test is constructed according to the works by Fritz Riemann ("Grundformen
der Angst") four basic structres Z (obsessive-compulsive), H (hysteroid),
S (schizoid), D (depressive) are ascertained in their personality typical,
not their clinical meaning by 20 items each. The four structures were translated
into 17 groups of motives and were examined in pairs with respect to their
amicability and influence (reinforcement, hindrance, relief or favouring,
colouring) in 136 comparing analyses. From a mutual hinderance a measurement
of the personality structure was developed, which also proved to be clinically
valid. The measurement of tension has got two main meanings: (1) rich,
multiple motivation full of tension with the integration being successful
(type Goethe) or (2) rich and multiple motivation full of tension but the
integration not being successful and symptoms being produced. The differential
diagnosis: successful - not successful is operationalized according to
the measures of the analysis of existential orientation (BA)), the measures
of therapy control along the simple rule: BA scores o.k., tension
o.k., BA scores not o.k. tension measures producing symptoms.
Character structures which are not clinically interpreted, but along
general motivation psychology, are "translated" into the following groups
of motives: Z (obsessive-compulsive): Z-perfection, Z-performance, Z-control,
Z-security. H (hysteroid): H-demanding attitude, H-freedom. H-hunger for
adventure, H-vividness, H-impressiveness. S (schizoid): S-distance, S-control
(measuring somthing different from obsessive-compulsive control), S-aggression
(indirect), S-identity (wholeness, homogenity), D (depressive): D-security,
D-conformity, D-harmony, D-devotion.
03 VS-vital
energy-scale ("ego strength")
There are two variants here: one is built into the CST consisting of
20 items and one is built into the analysis of existential orientation
consisting of 22 items. Psychodynamically the VS can be interpreted as
estimation of ego strength as 20 life items are asked which usually are
successful if a person possesses sufficient ego strength. Additionally
this gives an operational definition of ego strength: life satisfaction;
self-confidence; resistance; independence (2 items); confidence; self-esteem;
confidence in one's own abilities; getting love, recognition and understanding;
having true contacts; efficiency; ability to relax; vitality (3 items);
ability to assert oneself; certainty of goals; job satisfaction; joie de
vivre; knowing one's limits. The BA version also includes: ability to enjoy;
ability to tackle problems, The statistical limit of being relatively satisfied
and healthy turned out to be 14/20. The VS is suitable for therapy planning
as well as validly esimating success control. On the sum-score-function
(cardinal scale) of the VS see Sponsel (in preparation a).
04 PSBS- scale
of psychosomatic stress
Here 29 items are ascertained according to their frequencies (never,
seldom, sometimes, often) with assigned raw scores 0, 2, 5, 10 (Sponsel,
in preparation b). It is not rare that psychic-mental conflicts are expressed
in psychosomatic symptoms. It is included: trembling, blushing, diarrhoe,
constipation, sweating, stomach trouble, palpitaions, stabbing pain in
the chest, back aches, circulation problems, breathing problems, asthma,
exhaustion, tension, sleeplessness, tiredness, colds, seizure, restlessness,
infects along with high temperature, night mares, skin disease, allergies,
sexual problems. The scale is suitable for therapy planning as well as
for the control of therapeutic success, especially og psychosomatic strain.
05 GVS - scale
of ratio of emotions
Here 13 positive and 13 negative emotions and moods were choosen representatively
for all emotions and moods and calculated according to the categories (never,
seldom, sometimes, often) with the raw scores 0, 2, 5, 10 (Sponsel, in
preparation b). Then the relative share of positive emotions (G+%) on all
emotions were determined with a criterion-oriented expected norm interval
of scores between 60 and 80%. Higher scores express an exceptionally happy
period of life, expansive syndromes or an exceptionally strong denial of
negative emotions. The positive emotions and moods being joy, feeling of
well-being, good mood, love, strength, trust, happy, confidence, vibrant,
affection, recognition, power. The negtive ones being anxiety, annoyance,
inhibition, anger, distrust, sad, depression, envy, disappointment, tension,
hatred rejection, feeling of being ill. The scale is suitable for therapy
planning as well as for the control of therapeutic success, especially
for the condition regardring emotions and moods. The idea was promoted
by studying the works by Flugel (1925) and the Polish School of Emotions
of Reykowski (German 1973).
06 SKS - scale of
self-criticism
The SKS is asking for traditionally general human faults and weak points.
Someone is self-critical, if she/he is able to perceive and admit general
human weaknesses. A pilot study was validated on 100 cases. The item-matter
being assessed were: admitting annoyance; having secrets; admitting faults;
delaying; having antipathies; white lies; envy for others; bad moods; occasionally
lazy; sometimes irrationality; malicious joy; uncomfortable with criticism;
sometimes diplomacy. Findings: of 11 items the norm group reaches a percent
rank of 81, the case group (without expansive syndromes) reaches
PR 63. Psychotherapy patients tend so be often more scroupulous, more self-critical,
more strained by conscience (dominant on superego).
07 LZS - scale
of satisfaction in life
The concept is based on the homostatic model of motivation by Toman
(1968, 1978). The simple idea of curing is: relatively healthy and satisfied
people produce no or less symptoms. Thus: the score for satisfaction is
a indirect sign of a probable or real production of symptoms. Thus a normal
score should be determined being suitable as global measurement for health
and for estimating the risk for a displacement of symptoms. Evaluating
different areas the mechanisms of compensation and exchange can be studied.
This procedure is examined, documented and evaluated carefully and in detail
under 08 (SZS --scale of self-satisfaction) as part of my dissertation.
Additioanlly to the real satisfaction also the level of demands is
ascertained making it possible to get interesting information. 17 areas
of life are examined on a natural percentage-scale of seven verbal estimations
of markedness: work & job; friendships; recognition; money & possession;
relaxation; realization of interests; influence and prestige; Health; giving
love; receiving love; sexual fulfillment; familiy climate; living situation;
neighbourhood; self-realization; quality of life; fellow men. The scale
is suitable for therapy planning as well as for the control of therapeutic
success, and especially to control inter-psychic displacement of symptoms:
within eco-social systems, within families and with couples it can be worked
at by several persons, but the increase of satisfaction for one person
mustn't be at the expense of another.
08 SZS - scale
of self-satisfaction
Whereas the LZS includes more components, which life offers (or not),
the SZS is mainly related to the self. Usually the SZS scores are
higher than the LZS scores. This makes sense: usually we are more satisfied
with ourselves than with the the world and life. Sometimes this ratio is
inverted and indicate a specific problem of self-criticism and over-criticism
of the patient. 20 important dimensions of real self-satisfaction and the
level of demands are ascertained: outer appearance; ability to enjoy sensuously;
expressing positive emotions; expressing negative emotions; articulating
wishes; expressing honestly ons's opinion; intelligence; knwoledge &
education; professional knowledge; dealing with money; talents; openness;
self-confidence; trust; activity; tolerance; sense of tact; love of mankind;
readiness for responsibility; sexual lust.
09 FBS - scale of familiy
image
The FBS - scale of family image was developed in 1980 by a so-called
scaling of competent judges (qualified clinical psychologists). It allows
to judge the quality of an image as well as it is possible to determine
the similarities or identifications, the contrasts and the differences
when comparing two images. Thus also questions like the following can be
examined, e.g.: identification who with whom, choice of partner in accordance
or contrast with the mother, image of the father problematic or not, is
the therapist/counsellor identified with a parent (analysis of trasnference),
is the image of the partner positive, how well does A know B, etc.?
The quality of an image: The most important score regarding quality
is the P%=positive percenatge. It is calculated as follows: 100 * (raw
score positive : (raw score positive + raw score negative)); P% thus gives
the positive percentage of the whole image. Images of a percentage less
than 60 are to be calssified as significant and potential problematic.
Experience proved "ambivalent qualities" (40-59) to be difficult.
Sometimes it is easier to come to terms with a negative image than with
a "half and half image". Extreme scores, extremes at the edges and medium
choice were additionally ascertained. In any case a positive self-image
(at least >= 60% positive share) should go along with therapeutic success.
The standard survey is based on self image, image of the partner, image
of father, image of mother. Thus in the therapy of couples there are 8
images allowing 28 comparisons. From comparing the self- and partner images
result the 6 combinations by Harris (German 1975) (A: I'm (not) o.k., you
are (not o.k. crossed over by B: I'm (not) o.k., you are (not) o.k.) operationally
determined.
10
LGWS - life principles and value system. LG: life principles.
The scale of life principles is supposed to estimate the self-healing
powers interpreted as ability to solve problems and cleverness of life.
The model assumes that a good coping of life and ego-strength results,
if a number of life principles which are partly or in detaim contradictory
are available simultanuosly in the repertory of action of a person and
can be used depending on the situation according to given aims and purposes.
Thus: sometimes it is good to be real, but sometimes this is what is wrong
and it would have been better to be cautious. Often it is good to stand
up, but sometimes avoiding would have been better, etc. Relatively healthy
and satisfied people heed such relativity principles of cures intuitively
without consciously being aware of them. They are real and tactful, they
assert themselves and adapt, they are realistic and they dream. The variety
of principles, their appropriateness and their balance thus characterize
a person relatively able to cope with life. In detail the LG ascertains
5 vital ego-functions (authenticity, decision, problem solving, doing without
rationalizations, self-responsability) and 5 social ego-functions (adaptation,
differentiation, cleverness of life, realism, social understanding). The
LC score is the better, the higher the balanced scores are on the 10 sub-scales.
Each sub-scale is signed in a compressed way fromm +++ to ---, so that
it can be seen at a glance, where the problematic areas are.
WS: value system. The items of the valus system ascertain the personal
rating (order of rank) and the image of man (order of rank of projections)
and are evaluated in relation to each other. 6 value classes are determined:
SKGM: senses, body, pleasure, leisure). GLKO: emotion, love, contact. K…BI:
ability and education. LEAK: performance, success, activity. SICH: security
(material and immaterial). WEIS: wisdom.
11 GTT - brooding test.
Brooding we call thinking which always returns to the same problem without
reaching a solution. It's difficult to delimit it from the finally creative
problem solving, which may also take long until a solution is found. The
delimitation is not difficult, if it is psychologically clear, what the
algorithm of problem solving has to look like. There are a number of disorders
resulting in major brooding phenomena with the affected persons (you may
consider the depressed, the obsessive-compulsive, the narcissistic, the
optimizer, the worried and those solving problems). For a slightly better
discrimination and thus for a better therapy planning 7 scales of brooding
"types" (consisting of 5 items each) were constructed: prognosis brooders
(in large numbers pictures of negatively biased future events); goal brooders
(how do I reach (avoid) X?), decision brooders (it should / must be decided
with risk), certainty brooders (how can I be completey certain, that...?),
assertion brooders (I can (not) assert or prove myself, when I'm challenged),
effect brooders (particular interest in their effect on others), conscience
brooder (what is offered, forbidden or allowed?). The 35 items are ascertained
according to real estimations and how the person considers it to be desirable
and healthy.
The procedures 03 - 08 were summarized as analysis of existential orientation
(BA) for the purpose of therapy planning and controlling the success of
therapy.
5.2. Empirical
results and evaluation
(1) The global measures
of satisfaction. As part of my dissertation (Sponsel 1984) I created
a terminological basis and important parts of technical instruments to
control the success of psychotherapy particularly in the private psychotherapeutic
practice and integrated it into the CST system. In the technical part of
my dissertation two gobal measures were developed - the estimation of life
satisfaction (LZS, 17 items, 34 including aspiration level) and of self-satisfaction
(SZS, 20 items, 40 including aspiration level) - and evaluated (strictly
symptom- and criterion-oriented according to the integrative psychological
psychotherapy). Especially the scale level of estimation of satisfaction
was examined. Also it was shown, that the mean is independent of the weight
of the areas of features. The evaluation was based on N= 1091 surveys alltogether
and the following treatment and control groups wre built:
Statistical results
Norm- and control groups (Sponsel
1984, 301pp)
Mean
norm- and control groups all N=403....................
LZS=59,9 %
(563 including repetitions for reliability &
control)
all conspicuous (with symptoms) N=72 (loc cit. 313)
.. LSZ=53,0 %
conspicious (with symptoms) without specification
.... LSZ=53,4 %
N=44 (loc cit. 317)
conspicuous (with symptoms) without treatment ........
LSZ=52,4 %
N=28 (loc cit. 321)
inconspicuous (ideal norm group of those relatively
healthy and satisfied N=46 (loc cit. 325) ............
LSZ=66,9 %
Treatment groups all N=337
(528 including repetitions for prov'cess, reliabiliy
and control rol)
Mean
beginning phase N=52 (loc cit. 329)..................
LSZ=46,6 %
in between phase up to 1 year N=33 (loc cit. 333)....
LSZ=50,0 %
in between phase longer than 1 year N=24 (loc cit.
337)LSZ=54,9 %
treatment groups all up to 1 year N=69 (loc cit.
341) LSZ=48,7 %
check-up group more than one year after finishing
the
treatment N=27 (loc cit. 345) ........................
LSZ=64,1 %
evaluation group according to criterion orientation
i.e. on a wide range the disorders had disappeared
respctively were significantly reduced
Drop-out
studies
Mean
drop-out study up to 1 year after drop-out N=14 ......
LZS=48,1 %
drop-out study 1 to 2 years after drop-out N=16 ......
LZS=57,0 %
drop-out study without specification N=28 ............
LZS=57,0 %
drop-out without further treatment N=19 ..............
LZS=54,5 %
Weights of the areas of life:
main proposition: der mean of the life satisfaction is arithmetically independent
of the personal evaluation, i.e. its importance is already considered by
the clients when marking with a cross (loc cit. 132; the correlation between
evaluated and unevaluated means of life satisfaction is r=.96 for N=30
(measure of similarity=95%). In detail the
following order of ranks resulted (orientation: higher figure=higher
rank, R-rank, results ranks loc cit. 126):
receiving love .......... R10 giving love
............. R9 self-realization .........
R8 health .................. R8
friendships .............. R8 family
climate .......... R8
sexual fullfilment ....... R8 work &
profession ....... R7
recognition .............. R7 relationship
of interests R7
relaxing ................. R5 living
.................. R5
quality of life .......... R5 fellow
men .............. R5
money & possession ....... R4 influence
&
reputation .. R4
neighbourhood ............ R3
Special studies:
Additionally a number of special studies were carried through, which
are mentioned for information:
The significance of worksatisfaction (loc cit. 157)
The significance of satisfaction in love (loc cit.
203)
Connection trust and love (loc cit. 194)
The significance od self-realization (loc cit. 172;
262)
The significance of self-esteem (loc cit. 192)
The significance of life quality (loc cit. 174)
Analysis of breakthrough and authenticity (loc cit.
264)
Remark: For all groups also the level of aspiration of the satisfactions
was analyzed.
Norms: percent rank, with respect to three levels of education, five
age cycles and gender. Reliability: a reliability measure was developed
and evaluated for the individual case, not having the weak points of the
correlation coefficient (Sponsel 1994, 24-33), and for process and longterm
analyses (LZS=94.4% similarity and r=.934; SZS=95.5% similarity and r=.89).
Selectivity and analyses of regression and corelation were carried through.
Main results
relevant for psychotherapy:
-
Non-parametric: 81% of the treatment group are unsatisfied as oposed
to only 24% of the comparing control group of the "unconspicuous".
-
Parametric: the mean of life satisfaction lies around 46.6% with
the treatment group (beginning phase) and around 66,9% with the "unconspicuous".
It could be shown that the mean of life satisfaction is valid as global
measure for controlling estimation of therapy success and thus can also
be used to control displacement of symptoms.
-
The homeostatic
modell of motivation by Toman, allowing a reasonable psychological
interpretation of Freud's concept of libido - and thus tries to integrate
the psychoanalysis into the cumminity of scientific methods - is confirmed
- by these results: human beings need a minimum level of fulfillment of
motives in the long run, otherwise they develop disorders or get ill.
-
Displacement of symptoms. One of the
most important practical application could be, that the mean of life satisfaction
is suitable to control displacement of symptoms. For thid the following
considerations and the linked final figures may be helpful:
Given the global measure saying that scores, that G can reach indicate
with G>K (K=criterion) gobal psychic health. At the beginning of the therapy
one patient is said to have G(beginning)=45, K be 59.
G-case 1) Gend
< Gbeginning
G-case 2) Gend
= Gbeginning
G-case 3) Gend
> Gbeginning
For the markedness of syndromes we choose S and
then we get:
S-case 1) Send
< Sbeginning
S-case 2) Send
= Sbeginning
S-case 3) Send
> Sbeginning
The combination of global measure-cases and the markedness of syndromes-cases
results in nine possibilities:
markedness of syndromes
global measures
Send < Sbeg Send
= Sbeg Send > Sbeg
Gend < Gbeg
11 12
13
Gend = Gbeg
21 22
23
Gend > Gbeg
31 32
33
Interpretations:
11 Markedness of syndromes is smaller after therapy than
before, but also the gobal measure is smaller. Thus: strong susoicion of
displacement of symptoms. The patient doesn't suffer from pest anymore,
but only of cholera.
12 The situation has worsened.
13 The situation has worsened dramatically: as well on
the level of syndromes as on the level of global measure.
21 Situation has improved on the level of syndromes, but
this doesn't effect the global measure. Suspicion of displacement of syndromes.
22 Situation not changed.
23 Worsening: production of symptoms has increased, while
the global measure stays equal.
31 Ideal success of therapy: the syndromes receded and
also an improvement of the global measure resulted.
32 Although the sybdromes show no change, the global measure
indicates improvement. The patient can get along better with the syndrome
or she/he has settled down. Typical results of earlier psychoanalyses.
33 Paradoxical result: although the symptomes increase,
the global measure also increases. This case should be examined carefully.
For all investigations we recommend the general GIPT-validity-meta-rule:
the scores have to fit with the situation and the criteria of comparison.
If thy don't, special security measures, interpretation efforts and considerations
are necessary. Thus we found e.g. that the global measures we developed
have to be particularily carefully controlled with expansive processes,
with obsessive-compulsive isolations of symptoms and for specifical interest-oriented
situation (desire for pension, question of compensation, selection, expert
witnesses).
(2)
Empirical investigation on the trias hypothesis of Freud
The trias hypothesis by Freud, saying that somone is healthy, who can
work, love and relax, was examined by me empirically via items of the vitality
scale (scale of ego-strength) and was confirmed (Sponsel 1982-1984, 1.
supplement 08AV:02, 3,4,5-UV; V8, V11, V15-01 to 10). Under the condition
that three items are approved, the conditioned propability to confirm criterion
14 or more items of vitality is p= 0.88, to exceed the pathological
limit of the production of psychosomatics decreases by factor 9 from
p=.16 with the conspicuous to .018. Also the conditioned probalility to
reach a positive ratio of emotions of >=60% is 2,5 times higher under the
trias condition by Freud than with the conspicuous. The score of conflict
and tension for PR=50 (Median) is with the trias condition fulfilled only
400 (N=228) in the personality structure, 690 (N=635) with the norm group
and even 1030 (N=187) with the conspicuous, thus it si extraordinarily
valid. Besides the validation and evaluation of the measure of tension
constructed in CST results in a clear argument supporting
the utility of methods justified regards content as opposed to artifically
formal methods, like e.g. factor analyses.
6. Summary of
the Pratical Procedure on Evaluation and Success Control: 12 Points
Manual
(1) Case history of criterion-valid cures, case histories
and changes within the lebensraum
and life quality:
(2) Relatedness (partner, friend, family, neighbour, acquaintance)
(3) World of performance (work, profession, education,
learning, performance, career)
(4) Recreation, leisure, pleasure & fun
(5) Personal
CST system scales
(6) Personality structure within the CST, particularly
scores of tension
(7) Vitality or ego-strength
(8) Ratio of positive emotions and moods
(9) Psychosomatic stress
(10) Life- and self-satisfaction
(11) Family image, particularly self-image
(12) Other individual pecularities
Outlook
In future much attention within the GIPT will be given to the development
of criterion-valid cures and their constant diagnostic application within
the therapy process and to a methodology, which are consideres to
be really scientific - beyond to the scientistical mythology of numbers,
which is handed down so wrongly at the universities. (Sponsel 1994, in
preparation a and b).
Literature
Footnotes
(1) GIPT= the international
abbreviation of General and Integrative Psychotherapy.
GIPT substitutes the precious IPPT
(2) GDEIS = for
G_eneral,
D_ifferential,
E_clectical,
I_ntegrative,
S_chools
and methodes integrating psychotherapy
(3) The juggling with names
as it is practiced e.g. with the so-called "guide-line" therapies in Germany
is not at all questioned. For the behavioural therapy Wittchen (1996, 165)
is quoted: "Despite of thousands of practing psychotherapists calling themselves
behavioural therapists it is almost impossible to find colleagues who practice
an anxiety therapy according to the rules using cognitive or exposure techniques.
Margraf is said to have found similar results in a representative survey.
(4) GDEIS= G_eneral,
D_ifferential, E_clectical, I_ntegrative, S_chools and methodes integrating
psychotherapy. Necessarily the selection is shortened and subjective. I
do apologize to all who are not mentioned.
(5) Please see also the
digression on the history of the concept of cures.
(6) Exceptions: Ellenberger
and Hart brothers, who particularly appreciate the work of Janet.
(7) The first interdisciplinary,
general and integrative journal was published by Karl Philipp Moritz 1783
to 1793 with the title "Erkenne dich selbst - Magazin der Erfahrungs-Seelenkunde"
(recognize yourself - journal on experiential psychology), which in the
first volume contains a clearly general and integrative conception of psychotherapy
which is supposed to go back to the physician Marcus Herz. The journal
is structured in five main categories: (1) psychopathology, (2) psychology,
(3) diagnostics, (4) prophylaxis, (5) psychiatry and psychotherapy. Psychiatry
as well as psychology and psychotherapy refer rightly to this first empirically
interdisciplinary journal. It says in the preface that the journal is not
about "moral prattle" but about "facts" (I, p.8)
(8) Here we follow the historian
of psychology Max Dessoir (1902, p.367), contradicting the opinion that
there was no "mathematical" - meaning measuring - psychology before Herbart.
He thinks of the empirical measuring of time periods of after sensations,
which Tetens (1777, p.32-33) mentions in his publication. Choosing systematic
measuring and experimentizing for the birthday of empirical psychology,
it doesn't start with the physician, philosopher and psychologist Wilhelm
Wundt, but with the psychology of capacity by Nikolaus Tetens (1777, p.32-33)
who says about measuring after sensations: Even the length of the duration
of after sensations can be determined. Taking those which disappear the
quickest, but are strong enough to be perceived, the shortest duration
of this visual sensation is 6 to 7 thirds, with audial sensations it's
only 5 thirds and still less with after sensations of feelings." And in
footnote number 1 (p.33) he points out: "the impressions of feelings are
only half as long as audial impressions, as I know from experiments, which
I carried out, but this is not the place to describe them."
(9) It can be read in the
empirical psychology by C.C.E. Schmidt (Jena 1791, p.425), that the human
body e.g. is a orgaized ans self-organizing being.
(10) Heinroth talks of
Hevrisitcs. I thank the Germanist Prof. Dr. Naumann, Univerity of Erlangen
for explaining and proving that the term by Heinroth is equivalent to the
term Heuristics.
(11) For comparison: The
birthday of the general and integrative psychotherapy starts in 1803 when
Reil published his elementary work of 500 pages. Before Freud everyone
was working generally and integratively.
(12) Psychosynthesis. The
positive ressources oriented and integrative psychotherapy approach by
the Italien psychiatrist and psychotherapist Roberto Assagioli (1888-1974)
was first outlined in 1910 in his critical dissertation on the psychoanalysis
of Freud. At an international philosophical conference in 1911 in Bologna
Assagnoli pointed out his ideas about the unconscious. In 1926 the Instituto
di Psicosintesi was founded in Rome and was closed in 1938 by the faschists
(re-opening in 1944 in Florence). In 1927 the article "A New Method of
Healing - Psychosynthesis" was published. In 1965 the first main publication
came out: "Psychosynthesis: A Manual of Principles and Techniques" and
in 1973 the second main publication "The act of will". In 1957 the Psychosynthesis
Research Foundation was founded in New York. The basis of this approach
is the importance which is given to the healthy and positive and an open
and un-dogmatic attitude towards the variety of procedures, methods and
techniques developed internationally and on the basis of everyday life.
(Survey of around 40 "techniques" (in our terminology "methods") German
1993, p.63-65). Illness is only one - mostly contemporary - aspect, one
feature, one part of the complete human being having also many healthy
aspects and sources. As a hypothesis for research symptoms are seen as
blockades which have to be explored with regard to their meaning and function.
According to psychosynthesis the release of constructive sources often
makes the symptoms disappear. Psychosynthesis corresponds very strongly
with the class of cures 'activation of ressources' of the research group
Grawe et.al. (1994). Assagioli also deserves the merit to again have developed
and made useable for psychotherapy the old psychic elementary category
of will. After all he is the only more famous representative of a model
of psychotherapy who has developed an explicit and practical psychology
of will. Also the basic significance of values and purposes is emphasized
correctly. In contradiction to Freud - in accordance with humanistic Ego-psychoanalysis
and the humanistic psychotherapy - Assagnoli emphasizes 1) the significance
of the conscious, 2) the significance of positive ressources and 3) the
significance of present and future. The scientific importance which
is given to parapsychology is critically seen from the GIPT perspective.
Lit.: Assagioli, R. (German 1993, original 1965; German 1982, orig. 1973);
Crampten M., in Corsins, R.J. (German 1983, 1052-1073).
(13) BDP =
professional association of German psychologists.
(14) From 1971 to now.
Here it is often not recognized both by officals and by chair holders of
a certain school orientation, how this concept had been developed and spread
already in the early psychiatry and psychotherapy of the 19th century (Reil
1803) and reached a second peak around the turn of the century (Löwenfeld,
Münsterberg, Dornblüth) and made an extremely rapid development
in the 70s of the 20th century. The publications by Van Quekelberghe, Garfield
and Petzold already have built an extensive fundement since 1980.
(15) The communication
with the IEAP according to my experience is not easy.
(16) The publication is
to be evaluated in a differentiated way. It consists of three parts: 1)
metaanalysis without studies controlling the strength of effects; 2) prove
of effectiveness in favour of behavioural therapy (this has evoked a lot
of trouble and criticism) and 3) the development of the general psycotherapy
- also based on research results. The metaanalyses are naturally problematic
with respect to methodology as well as the scientistic concept of controlled
studies. Therefore I mainly refer to part 3)
(17) Presentation according
to Sponsel (1995, 289-290)
(18) With respect to the
authors we refer mainly to German publications.
(19) The Systematology
of Psychotherapy is the first large modern fundamental publication on general
and integrative psychotherapy. It was already written in 1977 and published
in 1979.
(20) For more details please
see Sponsel (1995, p.102-107), Sponsel 1997.
(21) For this period he
names as most important cures (curative factors): arts, culture, music
and the placebos: curious expecation, hope, belief, trust.
(22) Contains on page XIV
the neologism "psychological-therapeutic". It is organized in three sections:
"Materia medica", "Materia diaetica", "Materia psychica".
(23) From Reil also originates
the term "Psychiatrie" in: †ber den Begriff der Medizin und ihre Verzweigungen
(On the term of medicine and its branches"..(p.161), compare also Mechler,
A. (1966).
(24) in ¤3 (p.23p):
"Cures are matters, which we apply to animal bodies to try to make their
illness disappear. These matters can be of physical or non-physical nature,
substances from the world or etherical substances belonging to the cosmos,
they can work through mechanic, chemical or other forces. Thus their reality
is based on the relation between them and the purpose which they should
reach. Thus in the world existing as diversity according to the laws of
causality there are no matters having only the purpose to cure illnesses.
Their effectiveness is limited and as diverse as the objects theyare applied
to. The same matter which a medical professional uses to cure illnesses,
can also be used for other purposes, e.g. for destroying the organization
and thus in this other relation is a poison. The theory of cures thus has
no specific area (dominium) in the series of natural matters, which it
possesses, but chooses those matters being useful for the purpose of curing
the human body. Thus it is only allowed a whereabouts (domicilium), which
is not absolutely limited but changes, gets smaller and broader according
to the progress of skills. The same matter is food, if it is substituting
the loss of substance in a healthy body; it is medicine, if it reestablishes
lost health; and it is poison, if it destroys. With all this it always
stays the same matter. Therefore all efforts have to fail trying to draw
a line within the realm of nature by diatetics, pharmacology, toxicology
etc. and thus to seperate certain areas.
(25) In accord with the
classical logic we distinguish here between contradictory (white - not
white; feeling - not feeling, for instance desired with pain) and contrary
(black - white), sometimes contradictory and contrary coincide, e.g. with
the cure (curative factor) guiding the contradictory is not guiding and
the contrary is letting (Sponsel 1995, p.188).
(26) Mertens (1993, vol.
3, p. 1929, however, has to admit 100 years (!) after the "preliminary
statements" (Freud 11.1.1893), that there exists no elaborate theory on
this important issue" (curative factors within psychoanalysis). Nevertheless
they want to be a "guide-line" method.
(27) Quoted according to
Schipkowensky (1966, p. 236)
(28) Reil's suggestions
appearing phantastical, like e.g. a perfect theatrical illusion therapy
are all based on empirical reports and case reports, all these bold and
creatice ideas start from the observation e.g. sometimes delusion can be
cured presenting the illusion of fulfilling the delusional idea like on
a perfect Hollywood screene to the patient, e.g. seemingly, but convincingly
giving birth of someone delusional pregnant.
(29) On the sudden cures
see > Corsini`s "Konfrontative Therapie" Corsini R.J. (1983) vol. 1, p.555pp.
Quoting
Sponsel, R. (DAS). Psychotherapy
Research, Evaluation and Quality Management in the Practice of GIPT Internet
publication for General and Integrative Psychotherapy IP-GIPT. Erlangen
(Germany): https://www.sgipt.org/e/wisms/ptfevqs0.htm
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