Wednesday, February 5, 2014

On Saying No: Evidence Based Practice and the Hijacking of the Empirical

Reprinted from: ADVANCES IN DESCRIPTIVE PSYCHOLOGY, vol 9, Ann Arbor: Descriptive Psychology Press, eds: Davis, Lubuguin & Schwartz (2010SSRN Download of paper.


Poorly framed descriptions of psychotherapy serve as a pretext for the requirement that the efficacy of therapy requires demonstration through randomized control trials. Such restriction involves an inadequate conceptualization of the nature of psychotherapeutic engagement but is an understandable reaction to the conceptual confusion that continues to exist in most theories of psychotherapy.
Descriptive Psychology is offered as a partial antidote to this problematic state of affairs.

           Psychotherapists trained to engage in careful empirical examination, mindful of preemptive and limiting assumptions, who offer logically sound, empathic, and revisable descriptions and interpretations, live in a current climate where their hard won practices are vulnerable to a restricted vision of science, competence, and knowledge. Not all therapists respect scientific and empirical traditions, and it is reasonable to assume that not all practices called psychotherapy are generally or specifically helpful or effective.  It is reasonable to question the adequacy, intelligibility, and value of the various activities called psychotherapy.  None the less, under the banner of scientific accountability, psychotherapeutic practice may be subjected to conceptually improper methods of analysis.  The good may be lumped with the bad and the acceptable may be too restricted to make a difference in the real world.  These themes will be the subject of this essay coupled with my hope that the reader will recognize that Descriptive Psychology provides both concepts and methods that can clarify and protect the properly empirical from preemptive restriction. 
            Peter Ossorio, the founder of Descriptive Psychology, was famous for a teaching method that often started with his saying no.  He would say no to weak and sloppy thinking and to the aesthetic disregard that comes with undisciplined claims to knowledge. Poorly articulated but effective performance was worthy of his attention but he required the competent description of content if a topic was to be worthy of serious consideration.  He respected competence but demanded intellectual clarity. As he once put it, “things that are not intellectually satisfying tend not to be satisfying in other ways as well”. 
            Ossorio demanded of his students’ precise thinking and expression, clarity without assumptive restriction, a sort of play that demanded rigor without foreclosure of possibility. All conceptually possible options were to remain open in formulating a subject matter before establishing the empirically particular facts that happen to be the case. In his “What Actually Happens,” The Representation of Real-World Phenomena, (1975/1978) he affirmed his interest in totality.  Following Wittgenstein, a bit of Ossorio’s faith was the belief that language provides potential access to everything. He coupled his Maxim One, "that a person takes it that things are as they seem unless he has reason to think otherwise" with a distrust for claims of hidden or private meaning. He called his work “Descriptive Psychology”, in reference to the Philosophical Investigations’ reminder that, as Wittgenstein demonstrated,  if a description is adequate, “there is nothing to explain" (1953, p. 50.). Clarity and the detail of description becomes the first and central concern before explanation or theory matters.
            When I was his student, Ossorio often responded to my theories and formulations, my grand ideas, with “no”.  Then he would show me various ways out of my conceptual muddle.  Ossorio let me know he appreciated what I wanted to understand but was not so pleased with the way I went about it. Wittgenstein answered the question, "What is your aim in philosophy?" by answering, "to show the fly the way out of the fly-bottle." "No" was Ossorio's frequent first gesture in indicating the intellectual trap or dead end that I was headed toward.
            I was often asked by Ossorio to describe and then re-describe my various interests and observations. He would show me how to get better access to my themes by using the conceptual tools and procedures he had created or was developing. Many years have passed since my first lessons with Ossorio and Descriptive Psychology's concepts and the rules for their operation have been much expanded.  Ossorio has given us a workable guide to the rules of description, opening the door to an adequate unpacking of the key concepts of "Person", "Language", "Action", and "World".   ”Essence is expressed by grammar”, Wittgenstein said (1953/1958, p116e).  Ossorio developed an adequate grammar for behavior description and, in so doing, the rules for describing both the nuanced world and the form of our "essence".  With the example of Wittgenstein’s toolbox in mind, Ossorio taught that tools cannot all be of one sort but must vary with the range of the possible operations or actions performed. Because both personal action and the world’s terrain vary in a non-uniform fashion, behavioral descriptions and world maps require a complex grammar that does not derive from any single "root metaphor", (See Stephen Pepper on "root metaphors", 1942/1972). Everything does not, in one way or another, boil down to the same thing. Persons, languages, actions, and worlds are not really just machines, organisms, contexts, or formulations.
            The institutional setting for much of Ossorio's work was academic clinical psychology, which provided fertile ground to study possibly effective social practices that had been articulated incoherently. Of particular interest was the social practice of psychotherapy.  I teach in a school of professional psychology where there is acute awareness that the continued viability of psychotherapy as a respected professional activity is uncertain. Psychotherapy remains a vulnerable social practice and, I will argue,  a confused language game. 
            Ossorio's writings, which began during the 1960's and 1970's and continued until 2006, showed a persistent concern with the inadequacies of traditional theories and his continued refinement of his original insights into the grammar of behavior. During that time, it became painfully clear to a number of psychologists that, whether psychotherapy was helpful or not, the standard theories of personality and their associated psychotherapies were intellectually bankrupt. (See for example, the critiques by Roy Schafer, 1976, and George Klein, 1976 regarding psychoanalysis.) I do not think the average expected education in the theory and practice of psychotherapy has moved beyond this confusion except to acknowledge that there are many different therapeutic practices that should be respected in a manner that resembles respect for a neighbor's different (but wrong) religion.
            Wittgenstein ends the Philosophical Investigations with the diagnosis that the problem with psychology as a science is that we have "experimental methods and conceptual confusion".  Ossorio saw this problem when he first began his writing, and set out to correct it by formulating the foundational grammar of behavior and persons (1966 and 2006) and by investigating the practices of great therapists to see the sense and nonsense that they generated (1976). Still, given existing theory, the problem of claiming there is a scientific basis for psychotherapy continues (Godwin, 2009).
             Games or practices with muddled and contradictory descriptions and rules are hard to judge competently and fairly.  The referees speak past each other if they bother to speak at all.  None of this engenders trust or confidence and provides a justification for the powers in place to attempt to restrict play or commandeer the rule book.  Some of what we now contend with:  the second guessing of managed care, diminished insurance reimbursement, the “dumbing” down of training, and the restrictive tent containing the “official evidence based practices” are an understandable but reactionary response to unresolved confusions.
            Making conceptually incompetent scientific claims, the field of psychotherapy is vulnerable to an informed judge with the power to point to its scientific inadequacy. The mire we are in may result in the waste of sound knowledge and practice, brought about by financially driven concerns for effectiveness and cost control. These are legitimate concerns.  Psychotherapy takes time and time is money. The insurance industry has legitimate concerns with bang for its buck, and our training institutions and provider services echo these recognitions.
             For years now, various blue ribbon panels, when examining the claims of personality theory and psychotherapy, recognized the ongoing confusion and properly distrusted any of the grand narratives that came out of these fields. They cast a skeptic's eye.  My practice of psychoanalysis is a prime suspect (Gunbaum, 1993).  All the psychotherapies that claim kinship and are informed by the traditional personality theories seem automatically suspect. And reasonably so. (These same critics seem less inclined to acknowledge that the same conceptual problems regarding "scientific explanation" can be applied to cognitive behavior therapy and psychopharmacology (Godwin, 2009).) None the less, I have good experiential ground to believe that aspects of these suspect psychotherapies are well worth preserving, well worth devoting the time and money to their practice.  I also believe much of what we do is helpful, is life-enhancing, but I cannot easily demonstrate that claim within conventional scientific paradigms. I am going to argue that there are sound knowledge and practices that are demonstratively effective and can be described and taught with narrative coherence independent of a conventional but improperly restricted scientific paradigm.
            Science is necessarily tied to reliable formulation and evidence. This requirement has been problematic for many who practice good psychotherapy. Given the disorder and confusion of the psychotherapies, oppressive forces have entered to control the situation.  Using a conservative approach with public policy implications, these interested parties have learned to trust only a very restricted notion of empirical study and the experimental method.  They suspect many of us engage in “faith based” treatments and demand empirical accountability.  Mostly they require and have placed their faith in randomized control trials.  This coercive discipline serves as a remedy for real problems but like many radical remedies has serious side effects. (The operation was a success, unfortunately the patient died.)
           I think this situation can be corrected by Descriptive Psychology but since all knowledge is someone's knowledge, the actual correction requires the education of many more Descriptive Psychologists. The competent Descriptive Psychologist can demonstrate various forms of sound evidence required to assert that there are ways to practice effective psychotherapy that includes but is not limited to those that are suited for study in a randomized control fashion.  The first step requires cleaning up, when possible, the existing conceptual confusions.  Psychotherapists may also benefit from various fresh starts.  A variety of fresh starts toward a coherent psychotherapeutic stance has developed within the discipline of Descriptive Psychology informed by Ossorio's  status dynamic maxims (see for example, Bergner, 2007; Bergner and Holmes, 2000 and Schwartz,1979 and 2008).   Descriptive Psychologists competently perform in a manner that involves the social practices of psychoanalysis, cognitive behavior therapy, psychopharmacology, and  the status dynamic methods developed by Ossorio and his students. The Descriptive Psychologist knows how to "correct the grammar" and edit the claims of psychotherapists of any stripe.
            Given that there is, in fact, real conceptual confusion in psychology, certain organized bodies are attempting to restrict the meaning of empirical evidence in a historically familiar way. They tend to confuse the ideology of a limited or inadequate root metaphor with the range of what is real.  It is here again that Ossorio liked to say "no”.  He would say no to constrictive metaphysics.  He was especially irritated by the modern enthrallment with mechanistic world views and their attendant reductionisms and determinisms.  Ossorio frequently reminded his students that rule following systems, guarded by the status dynamic maxims he formulated in Place (1998), help create understanding as a guide to clarity.  Understanding was the fundamental criteria of successful knowledge with cause-effect predictions only sometimes a reasonable possibility.  He began with the claim that we are persons and not machines or other clockwork-like deterministic objects.
             Rules for behavior description in the form of Maxims rather than mechanisms were central tools for Ossorio.  The Maxims offer guidance toward well-formed descriptions and the practical use of empirical observation. A central reminder is that the empirical involves historically particular facts and distinctions that can be acted upon. The Maxims provide a grammar for the correct descriptions of what is observed (including the fact that their may be various correct descriptions).  "Correct" will be pragmatically tied to effective use or action.
            Since actions can be judged for effectiveness, it is this pragmatic criterion of effectiveness that allows a factual claim or description to rise above the random or the arbitrary. Descriptions are social constructions but they cannot be dismissed as merely "relative" as certain post-moderns might claim. Effect and serviceability are fundamental criteria for the adequacy of a correct description. We can always ask, "Is this description useful?" "Does it fit?", "Is it logically coherent?" and these are the concerns of Ossorio's Maxims. The Maxims are fundamental reminders and warning, and constitute an unpacking of the relationships of Person, Action, Language, and World.  They are content-free conceptualizations, constraint formulas, tautologies, and so, if well formed, should be timeless. They are reminders. ("The work of the philosopher consists in assembling reminders for a particular purpose.” Wittgenstein, 1953, p. 50.). Ossorio's Maxims were designed to protect the integrity of the concept of "Person".  He said about them, "the maxims serve as principles for giving empirically warranted behavior descriptions" (1970/1981).
            By 1998, Ossorio's list of Maxims filled a volume, Place, but they began with the following nine, first published in his Outline of Descriptive Psychology (1979/1981).

1.   A person takes it that things are as they seem unless he has reason to think otherwise.
2.    If a person recognizes an opportunity to get something he wants, he has a reason to try to get it.
3.     If a person has a reason to do something, he will do it unless he has a stronger reason not to.
4.     If a person has two reasons for doing X, he has a stronger reason for doing X than if he had only one of these reasons.
5.  If a situation calls for a person to do something he can't do, he will do something he can do.
6.  A person acquires facts by observation (and thought).
7.  A person acquires concepts and skills by practice and experience in some of the social practices which involve the use of the concept or the exercise of the skill.
8.   If a person has a given person characteristic, he acquired it in one of the ways it can be acquired, i.e., by having the prior capacity and an appropriate intervening history.
9.   Given the relevant competence, behavior goes right if it doesn't go wrong in one of the ways it can go wrong. (p. 80)

          The 1998 volume, Place, expanded, collected and explicated the Maxims to guide descriptions of persons and their worlds; behavioral choice; value and behavioral choice; stability and change; person and community; the interaction of persons; person and self; limits, constraints, and limitations; and norms, baselines and burdens of proof. Place reads like an extended prose poem fiercely articulated without a wasted word. 

The Meaning of Empirical Evidence and the Teaching of Descriptive Psychology

            When I teach Descriptive Psychology, I have learned to first orient my students to the distinctions that define the domains of the conceptual, the empirical, and the theoretical (Schwartz, 1988).  I want them to understand the need to conceptualize a subject matter before engaging in theory. I describe the task of conceptualization as clarifying the range of possible facts that identify a subject matter as a particular subject matter.  Concepts are the tools or action-based distinctions that allow us access to the subject matter’s historical particulars.  Well-formed concepts are as eternal as addition and subtraction. While concepts are timeless, the data are the historical instances that exemplify the concepts. In possession of a particular conceptualization, by having a particular subject matter in mind, we are then in position to collect the data, the facts, or the evidence of the particular content or nature of the subject matter.  For example, I tell my students that the subject matter of the unconscious, the concept of the unconscious, involves a range of possible facts that person "A" claims is descriptive of person "B's" actions or motivations while person "B" cannot (or will not) make that same claim regarding what he or she is doing. In this regard, person "B" does not think that person "A's" descriptions or interpretations of "B" fits. "B" has neither the power nor the disposition to accept "A's" status assignment. That is where we look, the non self-recognized status one person attributes to another person, when we say that someone is doing something unconsciously. I define theory as the concern with why out of the range of possibility only certain patterns of data empirically occur. Why, for example, are some observations of people's behavior routinely denied by the actor observed. For example, in early Freudian theory, the theory would attempt to clarify why a person might not know about their alleged incestuous and murderous desires while being fully aware of sexual and aggressive feeling directed outside of their family of origin. The conceptualization of the unconscious as a subject matter that concerns active but non self-recognized motivation is a legitimate subject matter independent of whether Freud's theory of the Oedipus Complex is an accurate or useful way to understand any particular actor's actual "unawareness" or behavior.
            Early in my lesson plan, I tell students about persons as linguistic self-regulators who are eligible to make choices and who, as persons, have the behavioral roles of actor, observer-describer, and observer-critic. I then show how these roles have formal connections to the concepts of Deliberate, Cognizant, and non-deliberate Intention Action (see Ossorio, 2006).  Using a top down approach that avoids both reductionism and determinism, starting with the full, most complex or indubitable case ( i.e., the paradigm case) I develop the tools for making paradigm cases and their parametric analyses (see Ossorio, 2006).  I try to show my students how to use the parameters of Intentional Action, a paradigm case of behavior, to effectively represent what they know about a behavior. I remind them that parameters locate the data of a subject matter in a fashion that resembles the parameters of plane geometry's "ordinate" and" abscissa"  or color's "hue", "saturation", and  "brightness".  I demonstrate to my students how the parameters of  Intentional Action,   "Want", "Knowledge", "Know-How", "Performance", "Achievement", and "Significance", provide a general format for the description and analysis of behavior and serve as a method for comparing different theories of behavior. I show students how specific parameters are pertinent to some behavioral theories while others may be neglected, ignored, or not deemed relevant.  I contrast, for example, the psychoanalyst's focus on the parameters of Want, Knowledge, and Significance, with the operant conditioner's interest in the parameters of Performance and Achievement, or the cognitive behavioral therapist's interest in reforming Knowledge sufficiently practiced to produce a different Know-How.
            I am especially interested in having my clinical students understand how knowledge (or insight) is different from the competence, skill, or know-how to act on that knowledge, and how a performance is conceptually distinct from the significance of the performance (Schwartz, 2002).  I also want them to recognize that psychological state and behavioral performance are to be articulated separately. They may need to remember that behavioral performances can be the manifestation of various psychological states just as a psychological state can be expressed by a variety of actions.
            Next, I unpack the Relationship Formula and its articulation of how a particular behavior reflects the eligibility to act in accordance with a particular relationship. I stress the logic of how relationships provide the eligibility to act in certain ways and not others. Then I teach how emotional behavior is to be understood as a variety of intentional action, that emotion is behavior that reflects the impulsive or immediate response to the appraisal of a particular state of affairs.  Finally, I show my students the Judgment Paradigm (Ossorio, 2006). 
            The Judgment Paradigm (Ossorio, 2006, p.228) with its dimensions of "relevant circumstances" and "reasons" and with its focus on the judge's personal or objective manner of giving weight to various reasons in decision making, is especially central in educating students about the use of evidence.  When clinicians claim that they provide effective psychotherapy, they are never in the business of proving their worth but rather of making a case for their worth by assembling what they take to be the evidence and making claims about the value of the evidence offered.  The world of the empirical, the world of evidence, is not the domain of proof but rather the domain of argument.  Like the lawyer’s dilemma, different judges have different criteria or standards for whether a case is successfully made. A good case can fall on deaf ears and a poorly made plea might be accepted. There is no way around this.  Every judgment is someone’s judgment.  Our parametric analyses point to the distinctions to make in gathering data or evidence.  The Judgment Paradigm organizes how the evidence is used by the particular judge in question.
            I wish psychologists, in general, understood these elementary themes and their parameters.   Descriptive Psychology offers a coherent, rational, and useful set of distinctions to hold in mind when acquiring data or evidence. We have the tools for articulating what actually happens. Psychology at large does not.   
            I think we face the hijacking of what counts as “empirical”.  I think a significant portion of the meaning of empirical evidence has been deleted as unacceptable to the “evidence based practice” movement’s compilation of “empirically-based therapies”. 
            The two broad and logically connected versions of the basic meaning of “empirical” refer to either the knowledge gained from competent practical experience or to the knowledge gained from the experimental method. That is how the Oxford English Dictionary tells it and I think that definition is a reasonable place to start.   But, and here’s the justification for a restricted definition, when a field is rampant with conceptual confusion it is harder than need be to judge the claims that come from practical experience.  It is hard enough without conceptual confusion.  The demonstration of competent practice and intervention requires their description to be part of public discourse. This central problem may be the undoing of applied psychology. And maybe worse, as Wittgenstein reminded us, the “problem” of psychological "science" is experiment performed with conceptual confusion.
            Evidence-based practice ideologues may be coercive and confused but they have the data, the empirical evidence that comes from experiment. They have significant knowledge that reliably comes from experiments and correlational studies of a certain restricted sort.  Currently, they are shaping the narrative that is offered as science by restricting claims of value to their restricted notion of what constitutes science.  They have reacted to the poorly conceptualized descriptions and theories of psychotherapy as something they correctly see as needing remedy.  But their remedy may clear up a symptom while killing the patient.

An Alternative

            I want to reintroduce the “Local Clinical Scientist” and the “Natural Historian” as roles for the clinical psychologist. For both the scientist and the historian, the empirical is at the heart of their experiments and their narratives.  Later, I am going to come back to these players and their roles and suggest that Descriptive Psychologists are the quintessential “local clinical scientists” and “natural historians” given their rigorous approach to empirical description and judgment.
            Remember, the conceptual is distinguished from the empirical, pre-empirically, i.e., the conceptual establishes the range or domain of the subject matter but not it’s specific "to be found out" empirical content. You have to go out and look to find out what is actually happening.  As Descriptive Psychologists we start by not foreclosing on the data. We do not restrict the empirical before we take a look. Clinical looking is generally local. The theoretical becomes relevant, when it does, as a manner of explaining the particular organization of the subject matter’s data.  Why, for example, do we find some patterns of data but not others?  Are the local patterns suitable for generalization?  The explanation of pattern and its possible prediction within a subject domain is the principal value of theory.  Psychology, in common with many academic subjects, has historically confused the theoretical with the conceptual. This confusion, in turn, distorts the representation of empirical knowledge.
            Why am I concerned with “randomized control trials” (RCTs) and those agents who insist that RCTs are the required gold standard for appraising the worth of psychotherapy?  Limiting knowledge of effective psychotherapy to RCTs involves a preemptive restriction of the meaning of the empirical, a disregard of actual “evidence informed psychotherapeutic action”.  Notice I am using the phase, “evidence informed”.  I use that phrase in my narrative of the role of the local scientist and natural historian.
            I use the phrase, "evidence informed", to resist the coercion of those who attempt to restrict the practices of psychotherapy to activities that most easily allow some version of a randomized control trial. The RCT provides a restrictive but demonstrable base of operation.  But, as Ray Bergner (2006) has clarified, there are many secure bases for psychotherapy, both empirical and conceptual.
            So what is the problem with RCTs?  I am not claiming that there is not a legitimate domain for this method and the knowledge it provides.  Fortunately, we have a rich and respectable literature about these findings and their limitations.  Peter Fonagy (2005) and Drew Westin (2004), two prominent critics and practitioners of RCTs, have offered detailed meta-analysis of what these trials have uncovered and about the limitations and distortions of psychotherapy that RCTs also require. I will list some of these issues.

A List of Issues

            There are current and easily accessible websites that organize the evidence for the effectiveness and ineffectiveness of certain psychological practices.  Most of this research on “empirically supported therapies” has been the results of RCTs.  Summaries of much of this research are collected by the Campbell ( and Cochrane ( collaborations available on the internet. All this is useful to know and to incorporate into clinical work.  It would be negligent not to.
            Along with the positive value of knowledge gained by RCTs there are significant limitations and assumptions that guide this research. Some of the limitations and assumptions are highly problematic in the application of RCT driven research to common clinical practice.  There are methodological problems intrinsic to an examination of the practice of psychotherapy. The relationship of the local to the universal is at the heart of the problem.
            Generally, randomized control designs require or have employed a single axis 1 disorder with a restricted subject pool to ensure homogeneity.  The research design starts with the symptom clusters identified as mental disorders in the psychiatric medical model oriented, Diagnostic and Statistical Manuel. The first assumption is the problematic but conventional claim that psychotherapy treats mental illness. Ignored or excluded are the complex patterns of personality and life that the clinician sees in the average expected practice.  Also, these designs require treatments that are manualized and are of brief and fixed duration and involve outcome assessments that focus on specific predefined symptoms. [see for example, Westen, et. al. (2004) and Fonagy, et. al. (2005)].  Drew Westin and others point out that many of these studies assume or require malleable pathology that brief interventions can effectively fix, that the patients studied can be treated for a single disorder, and that personality factors are not particularly relevant to treatment.   Good luck in finding that set up in what usually brings people to psychotherapy.
            RCTs have high internal validity but come with the cost of a severe constraint on external validity given the necessary assumptions that have to be made regarding testable populations. The problem is not just with the variability of patients but also the variability of therapists.  Tip O’Neill, Jr., famously said that “all politics is local”, and much the same can be said about what therapists do in their offices.  Can  the successful therapist follow a general manual given the actual conditions of the work? The idea of the manual is an interesting problem.
            It has been many years since any serious psychoanalyst or psychotherapist conceptualized him or herself as essentially an instrument, exchangeable with anyone else of similar training.  The therapist as an instrument operating on a patient is way too reductionistic a metaphor for the interaction of persons but it is compatible with the notion that our work can be manualized.  Persons are obviously more than mechanistic instruments even if much of classical personality theory describes people in mechanistic terms.  In my field of psychoanalysis, the idea of the relationship of the analyst and analysand as the fundamental unit is a recent attempt at correcting this misconception. These days, psychoanalysts often describe their work using concepts and conceptualizations such as “inter-subjectivity” and "the emergent state that follows from the intimate engagement of two agents with self-reflective intentionality".  (But imagine the nature of psychoanalytic discussion in the absence of an adequate conceptualization of intentional action.) 
            This concern with intentionality was the first concern of Descriptive Psychology. We have an adequate analysis of the concept of intentionality in its various forms that include deliberate, cognizant, and non deliberate intentional actions.  As far as I can tell, no one else does.
            I suppose if therapy manuals were written by Descriptive Psychologists, I would be happier with them. Given our knowledge of status dynamics, the relationship formulas, the judgment paradigm, and our comfort and skill with "unless clauses", we might write serviceable ones.  Actually, I think we already have a guide to their construction in Ossorio’s, Place.  Wittgenstein wrote, “A philosophical problem has the form:  “I don’t know my way about” (1953, p. 49e.). Similarly, people seeking psychotherapy often begin with the recognition that they are lost. They may know that their map of their world and the personal characteristics they employ are keeping them trapped or lost. They need something new and different and probably not "one size that fits all".   Wittgenstein embraced the local as varied and irregular when he wrote, “There is not a philosophical method, though there are indeed methods, like different therapies” (1953, p. 51e.).  That quote resonates with the spirit of Ossorio's work.
             Everyone knows that RCTs can’t teach us enough about how to practice.  The American Psychological Association Task Force on evidence-based practice separates the dimensions of “efficacy” from “clinical utility” in evaluating the findings of RCT driven psychotherapy research (APA, 2006).  With this in mind, the APA task force developed the following alternative definition:  “Evidence-based practice in psychology is the integration of the best available research and clinical expertise within the context of patient characteristics, culture, values, and preferences.” This alternative is progressive and makes sense but keeps the original problem of conceptual confusion unaddressed and is unlikely to pacify the concerns of insurance companies and regulatory bodies. I am very happy with the task force’s recognition of the concept of “clinical expertise”.  This, of course, is a competence notion and respects the value of hard earned practical experience.  But again, this does not fix the confused way many competent therapists talk and write about their work. It is, at times, very hard to tell what competent psychotherapists actually observe and do.     
            Another issue:  I want us to remember that there is an underlying assumption in much of the RCT research that psychotherapy is concerned with disease or disease-like problems rather than dilemmas of intentionality or the meanings and significance of a person’s actions in their world.  Health insurance does not happily fund what I believe many of us provide and provide effectively.  Here, we may be in collusion with a pretense that our actions are to be understood within the social practices of the physician rather than the psychologist. RCTs sometimes provide a reasonable methodology when symptoms of a specific disease are at stake but not when we are confronting a person’s problems in attempting to live a good life. We only sometimes act as physicians.
            Pained by feeling depressed and anxious, confused about their skills, responsibilities, and ambitions, thwarted in seeking intimacy, sometimes envious and insecure, often guilty and ashamed, the people who come to my office want to feel better and live better lives.  They might see themselves as sick or crazy, as a patient suffering an illness, but the help they want comes largely in a growing sense of being understood and appreciated.  I think the kind of work I do often centers on helping my clients see themselves as agents rather than patients.  Rarely are they actually sick or crazy. The work they need comes not so much from being doctored, but in finding an honest and trustworthy companion equipped in the art and science of navigating a way through their world of persons.  People need to see themselves and their worlds straight in order to adequately deliberate regarding their actual opportunities and dilemmas.  As psychologists we are questionable companions if we carry a confused map, and especially if our map is packaged in advance of our encounter and explorations. Here the local scientist or natural historian takes on the explorer-guide's role in the cartography of the journey as it is undertaken.  Descriptive Psychology provides roles and tools for the exercise of judgment and sensitivity to personal circumstances in the competent map making and map sharing with our clients.
             So I am aware that the goals of “managed care” to treat a symptom or a disease may not always be my goals and may be a bad fit for the concerns of the people who provide me with my income.  In earning my living, I am more or less cognizant of my “bad faith” when I fill out insurance forms in collusion with my clients, there described as diagnosed patients.  Only sometimes do I act as a physician.  We betray our subject matter when we wed ourselves completely to the medical model's vision of problems in living as due to disease.  But even within the medical model we can provide the service of a clean description of the relevant facts.  Assessment and diagnosis go hand in hand. As psychologists, we are good companions who only sometimes engage in social practices akin to medical treatment.
            But what is my actual “good faith” practice and identity as a clinical psychologist?  I am a scientist and an historian of the local and natural sort. I make this status claim with the authority that comes with competence in practicing the discipline of Descriptive Psychology.  I know how to provide useful descriptions of what I observe and critiques of my descriptions and the descriptions of others.  As a practitioner in the neutral, atheroretical concepts and formulations of Descriptive Psychology,  I can provide a description of a state of affairs that any competent judge can evaluate.  This is why I teach the students in my supervision seminar crucial features of Descriptive Psychology (Schwartz, 2008).  Supervisors of psychotherapy work with the descriptions of someone else, their evidence is always, in part, second hand hearsay. Descriptive Psychology has the concepts for helping our supervisees articulate what has happened in their or someone else’s offices.
            As a Descriptive Psychologist, I recognize that there are many ways to evaluate the empirical evidence regarding psychotherapy.  The methods of the scientist and historian are not limited to the application of one research design. Both scientists and historians develop an attitude of respect for the logical and the empirical.  This attitude of respect serves as a foundation for these disciplined roles. Scientists and historians engage in a disciplined application of the esthetic concerns for coherence, elegance, completion, closure, and fit. They make use of varied forms of logical argument. They require their knowledge to be public, logical and teachable.  Scientific knowledge or the knowledge of the historian must be presented in a manner where an outside observer can repeat or understand an observation or action and can come to his or her own conclusions regarding its adequacy and use.  I can see and understand what you describe and can in turn offer a critique that you can understand (even if you continue to disagree).  We can share the data.  A humane but scientific attitude is called for in our work which is why Stricker and Trierweiler (1995) propose that the model for the clinical psychologist is that of the “local clinical scientist,” a model with kinship to my idea of the classical nature historian.
            Think of the pre-Darwin style of nature historian.  He enters the forest and records the color of a sphagnum growing at the base of a particular oak.  He describes the different insects and worms that move through this moss at different times of day and records that they feed at dusk and night and not when the sun is over head.  He records the date, the temperature, and the humidity.  Precise locations are marked on his map. He has a set of parameters for an observational walk through the woods. Looking closely, he observes and records that a particular worm leaves a tailing that feeds a particular beetle. This beetle tunnels through the moss and lays an egg that creates a larva that digests a line of bark on the tree.  The crevices formed in the bark holds the moisture that sustains and anchors the moss. This old fellow sees God’s handiwork in all this interconnection and writes that down, too. Years later, I read his journal and go have a look.  The tree has long since fallen but another of the same species is near the original plot. As a post-Darwinian I, too, am awed by the interconnections but reach different conclusions about how these patterns came about. But I can follow the first fellow’s path and make use of his descriptions.  I know why I disagree with him but I can see the same pattern he observed. The woods have changed some but I can use his observations when I take my look.  So it is in our work as clinical psychologists.  We notice and share the patterns and connections.
            The scientist and the historian ground their practice on practical experience in the full sense of the empirical.  They require effective practices that can be shared and taught. They require conceptual distinctions that make a difference in use or effect. Science and History require a body of public descriptions that any competent critic can address.  A randomized control trial can only validate a narrow range of knowledge or effect. There are many more way to know what is known.  Reliable scientific or historical knowledge requires systematic, comprehensive observation and description ground in conceptual clarity and not a one size method for establishing what is of intellectual or practical value. Real scientists and historians need to know why they agree or disagree with each other whatever the methods they employ, and that requires shared public discourse. Descriptive Psychology provides a neutral language for shared public discourse usable by all competent therapists whether or not they also employ a particular set of theories.
            What then do we make of conventional psychology’s representation of psychotherapeutic knowledge?  The expression “psychobabble” comes easily to the critics of psychotherapy.  Psychotherapists too often speak from a Tower of Babel. Engaging in psychotherapeutic social practices, we notice patterns, make connections, and decide how to intervene.  With our clients, we construct understanding and invent social practices in the service of helping them find their various ways.  In our psychotherapeutic relationships we take a variety of appropriate and individual stances as we learn to help. But we have a devil of a time representing this work to someone who did not participate.  Knowledge is public but psychotherapeutic knowledge developed behind closed doors, coupled with confused theory, often seems a kind of private language, one reasonable to distrust.
            Does the competent practice of psychotherapy help improve a life?  I have no reason to doubt that it can and often does.  Descriptive Psychology provides the distinctions and conceptual scaffold suitable to make such a claim.  I hope this knowledge is not lost.  I have tried to argue here that there are many varieties of sound knowledge and competence.  Some varieties easily fit into the traditional positivistic methods of ordinary science, some can be verified through randomized control trials, and some, the knowledge and skills most vital to effective psychotherapy, come from the practice of systematic and empathic observation, description, and critique. Systematic description fosters a record that can be shared and revised, facilitating the reasonable agreement and disagreement between interested parties.  Agreement or disagreement becomes useful and reasonable, suitable for negotiation, when the discourse is based on shared empirical facts and logically proper formulation, a state of affairs that gives each party access to the other's perspective.  Descriptive Psychology offers our best hope for sharing and negotiating psychological knowledge and practice, acquisitions too valuable and hard won to lose.


American Psychological Association (2006). Evidence-Based
    Practice in Psychology. American Psychologist, 61(4), 271-285.
Bergner, R. (2006). The Many Secure Knowledge Bases of
    Psychotherapy.  American Journal of Psychotherapy, 60(2), 215-
Bergner, R. (2007). Status Dynamics: Creating New Paths to
    Therapeutic Change. Ann Arbor, MI: Burns Park Publishers.
Bergner, R., & Holmes, J. (2000). Self-concepts and self-concept change: A status dynamic
    formulation. Psychotherapy, 37, 36-44.
Fonagy, P., Roth, A., & Higgitt, A. (2005). Psychodynamic psychotherapies:  Evidence-based
   practice and clinical wisdom. Bull. Menn. Clinic, 69(1), 1-58.
Godwin, S. (2009, June).  Can Psychotherapy be Scientific?  Paper presented at 35th annual meeting
     of the Society for Philosophy and Psychology, Indiana University, Bloomington, Indiana.
Grunbaum. A. (1993). Validation in the Clinical Theory of Psychoanalysis: A Study in the Philosophy
      of Psychoanalysis New York: IUP Press.
Klein, G. (1976). Psychoanalytic Theory: a study of essentials. New York: IUP Press.
Ossorio, P. (1975).  What Actually Happens. Columbia: University of South Carolina Press.
Ossorio, P. (1981). Notes on Behavior Description, In Davis (Ed.), Advances in
     Descriptive Psychology, (Vol. 1, pp. 13-36.).  Greenwich, CT:  JAI Press.
Ossorio, P. (1998).  Place. Ann Arbor:  Descriptive Psychology Press.
Ossorio, P. (2006). The Behavior of Persons. Ann Arbor:  Descriptive Psychology Press.
Pepper, S. (1942).   World hypotheses: a study of evidence. Berkeley:  University of California Press.
Schafer, R. (1976). A new language for Psychoanalysis, New Haven: Yale University Press.
Schwartz, W. (1979). Degradation, Accreditation, and Rites of Passage. Psychiatry, 42(2), 138-146.
Schwartz, W. (1988). What makes something psychoanalytic? Psychiatry. 51(4), 417-426.
Schwartz, W. (2002). From Passivity to Competence:  A Conceptualization of knowledge, skill,
      tolerance and empathy.  Psychiatry.  65(4), 338-345.
Schwartz, W. (2008). Self presentation and the status dynamics of psychotherapy and supervision.
       American Journal of Psychotherapy. 62(1), 51-65.
Stricker, G. & Trierweiler, S. (1995) The local clinical scientist. American Psychologist. 50,995-100
Westen, D., Novotny, C., & Thompson-Brenner, H. (2004). The empirical status of empirically
       supported psychotherapies:  Assumptions, findings, and reporting controlled clinical  trials.
       Psychological Bulletin.130(4), 631-663.
Wittgenstein, L.  (1953). Philosophical Investigations  Oxford: Blackwell.

Anthony Putman sent this to me while he was editing, Ossorio's seminar, "Positive Health and Transcendental Theories".

He didn't always say "No" and you weren't always wrong.

from "Seminar on Positive Health and Transcendental Theories", Session 10:

Wynn: There's a way, though, that's kind of interesting in terms of this actual construction as a part of the apprenticeship into a particular domain, because although it's Carlos's dream, don Juan—throughout the apprenticeship—suggests what he will encounter, and it's no accident that when Carlos finally reaches the point of stopping the world, of leaving the support of his normal sense of being, he enters into a domain that fits the description that he's already been led to expect should be there, from don Juan. So by a long series of exercises, in which first he visits one part of the dream world and then he visits another part of the dream world, he gets to have a fabric or map of what could be that world, which is relatively complete, such that—almost as if by acting in a variety of forms of life in the dream, he ends up with a complete world, a complete, coherent world.

Peter: I think it's important that, in the dream, he isn't just there; he's doing something, he's acting. And that's also a basic kind of practice. It's like the image practice that it's one thing to look at pictures of unicorns and be able to recognize one, or to have a dream in which you see a unicorn and then you can recognize one. It's something else to—in your dream—say, chase the unicorn or be chased by one or get up and ride him or touch his horn, because there you're getting the experience of acting in that world. You're getting the experience of acting with respect to the very kind of thing that you encounter in the dream.

Wynn: Through action, that world becomes coherent, and it ends up being a real world in that it becomes one that he can enter into and have coherent experiences in.

Peter: Yeah. Which means that if you have a normal perceptual experience of it, you also have built in how to treat it, because that you've practiced, too, in the dream, and you've practiced them together. You've practiced not only seeing it, but also treating it as being what you saw. And that gives you pretty much all the ingredients you need for then, suddenly, actually seeing one, and then you already have a repertoire to call upon by way of dealing with it.

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