Drawing on the classical thought of James and Dewey, I outline orienting perspectives, attitudes, values, and concerns that guide our efforts to establish a
Toward a Clinical Pragmatism 17 working formulation of clinical pragmatism in therapeutic practice. I explore the ways in which the core elements of pragmatic thought inform critical thinking and decision-making over the course of the therapeutic process, focusing our attention on crucial aspects of help and care, and show how the basic principles of pragmatism enlarge conceptions of therapeutic action and facilitating processes across the foundational schools of thought.
Individuality, Subjectivity, and the Human Particularity of the Therapeutic Process
In working from a pragmatic perspective, we focus on the individuality of the person. James centers on the realm of subjectivity, where he finds “a uniqueness that defies all formulation” (1911/1979, p. 109). When we engage “private and personal phenomena,” he proposes, “...we deal with realities in the completest sense of the term” (1902/1985, p. 386). Above all, he emphasizes, our experience is personal, every' sensation, feeling, image, thought, or action is mine or yours. “The only states of consciousness that we naturally deal with are found in personal consciousnesses, minds, selves, concrete particular Ts and you’s” (1893, p. 153). Dewey, emphasizing notions of personal agency, regards the individual as “the carrier of creative thought, the author of action, and of its application;” in his account, the “individual mind” is “the vehicle of experimental creation” (1925/1998, p. 12). James and Dewey both recognize the ways in which the changing contexts of experience influence what we see, hear, feel, think, and do, shaping the course of meaning and understanding.
Pragmatic values center our attention on the subjectivity of the individual, notions of personal agency and self-determination, and the unique circumstances of the clinical situation that defy categorization, deepening our appreciation of the complexities, ambiguities, and contingencies that inevitably shape the therapeutic process. The pragmatic perspective, accordingly, challenges a “technical rationalism” and reductive approaches to help and care based on rigid adherence to particular models of intervention, empirical findings, or technical procedures.
For example, although cognitive-behavioral therapy is widely regarded as the gold standard of treatment for post-traumatic stress disorder, other approaches have proven effective as well, including psychodynamic psychotherapy, humanistic and experiential forms of psychotherapy, hypnotherapy, mindfulness meditation, eye-movement desensitization and reprocessing, and yoga (Lambert, 2013; Wampold, 2010). In one of the largest studies of cognitive-behavioral treatment, Bessel Van der Kolk reported in his influential account of trauma, The body keeps the score, more than a third of the patients dropped out, and many' suffered adverse reactions (Van der Kolk, 2014; also see Shedler, 2015). Different approaches prove more or less useful in light of the particular circumstances of the clinical situation as well as differences in personality and temperament, values and sensibilities, capacities and skills, and earlier experiences of help and care. We cannot know in advance what will prove to be “therapeutic” in light of the actual possibilities and constraints of the given case.
While standardized treatments focused on specific disorders and symptoms have their place in the broader landscape of clinical practice, pragmatic thinkers propose that effective outcomes depend largely on idiographic approaches based on our recognition and care of the whole person as an individual and the ways in which practitioners and patients make use of different elements in the clinical situation, rather than on nomothetic approaches that impose rigid models of intervention.
Although educators and scholars often frame psychotherapy as if it were a research-driven practice, guided by empirical study, protocols, and technical procedures, Brendel points out that “hard-nosed” and “inflexible diagnostic and therapeutic approaches”—even if researchers regard them as “evidence-based”— potentially harm patients, failing to take account of the range of conditions that influence capacities to make use of different approaches in the clinical situation (2006, p. 23; also see Messer & Kaslow, 2020; Shedler, 2015; Wampold, 2010). The principles and values of pragmatism help us justify and defend what we are willing (and unwilling) to say and do as we carry out our practice. I explore these concerns further in my accounts of clinical practice in Chapter 9.
Relationship, Collaboration, and Interactive Experience
Following Dewey’s accounts of the crucial role of relationship and collaboration in our efforts to work toward understanding and action, pragmatic approaches reaffirm notions of egalitarianism and participation, emphasizing the fundamental importance of dialogue and an open-minded, deliberative process between the practitioner and the patient as they explore concerns. Clinical formulations are provisional, shaped by the patient’s capacities to make use of different elements in the therapeutic process, experiential learning, and concrete outcomes over the course of care.
We continue to recalibrate our understanding of the authority' of the practitioner and the patient in our conceptions of the therapeutic relationship, challenging views of the clinician as the all-knowing expert. Following developments across the foundational schools of thought explored in Part III, clinical scholars increasingly think of both parties as vulnerable, fallible, and capable, seeing the therapeutic endeavor as an active, searching process, facilitated through critical inquiry', dialogue, experiential learning, action, and reflection on outcomes (Berlin, 2005; Borden, 2013, 2014). The patient and the therapist bring their authority of experience to bear, revising their understanding of matters in light of ongoing outcomes. In accordance with the notion of fallibilism, we accept the limits of our understanding and remain open to experiential learning that deepens insight and informs action.
Researchers continue to document the crucial role of the quality' of the relationship between the patient and the practitioner, the strength of the therapeutic alliance, and collaborative interaction in outcomes across the foundational
Toward a Clinical Pragmatism 19 schools of thought (Borden & Clark, 2012; Kazdin, 2007; Messer & Kaslow, 2020; Norcross & Wampold, 2018; Shedler, 2010; Wampold & Intel, 2015). We can trace the concept of the therapeutic alliance to Freud and the first generation of psychodynamic thinkers, but clinicians across the schools of thought have come to recognize it as a core condition of all forms of practice. Even therapists who embrace a technical eclecticism now regard the alliance as a necessary if not sufficient condition of change.
Researchers have emphasized three domains of concern in their formulations of the therapeutic alliance: the attachment bond between the patient and the therapist; mutual agreement on the goals of treatment, and shared understanding of the core activities of the therapeutic process (Horvath & Bedi, 2002). Following reformulations of therapeutic action in relational psychoanalysis, however, practitioners increasingly think of the alliance as an ongoing process of negotiation between the patient and clinician about tasks and goals, emphasizing the mutuality' of the therapeutic process (Safran, 2012). The therapeutic alliance is the one of the most powerful predictors of therapeutic outcomes (Lambert, 2013, 2015; Messer & Kaslow, 2020; Norcross, 2011; Norcross & Wampold, 2018; Wampold & Intel, 2015).
As we will see, clinical scholars propose that the therapeutic relationship and the dynamics of interactive experience foster change in multiple ways. In the domain of interpersonal neurobiology, researchers believe that the core conditions of the therapeutic relationship engage biological mechanisms that enhance neuroplasticity'. New and different way's of relating potentially alter networks of association in neural structures, including motives, emotions, and defensive processes linked to subjective states, representations of self and others, and behavior (Borden, 2009; Gabbard & Westen, 2003; Schore, 2019a, 2019b; Westen & Gabbard, 2002a, 2002b). The experience of attu-nement and synchrony in the interactive experience and the constancy of care in the holding environment, mediated by' right-brain modes of communication, may strengthen internal functions instrumental in the regulation of emotion and subjective states (Borden, 2009; Schore, 2019a, 2019b). Ongoing interaction facilitates efforts to process and formulate experience, deepen capacities for reflection, and develop more functional patterns of behavior through the dynamics of internalization, modeling, and experiential learning. The working alliance serves as a catalyst, helping the patient more fully engage the core activities of the therapeutic process and make use of enriching relationships and activities in everyday life (see Wachtel, 2011).
Pluralist Orientation, Bridging Scientific and Humanistic Domains of Understanding
In accord with the pluralist orientation of pragmatic thought we recognize the value of scientific and humanistic realms of understanding, working to master a range of orienting perspectives, theories, therapeutic languages, models, and methods of intervention.
In the domain of science, emerging lines of study in the fields of genetics, neuroscience, evolutionary' biology', and developmental psychology' continue to strengthen our understanding of vulnerability', problems in living, and therapeutic practice. As a teacher and practitioner I follow developments in empirical research across diverse fields of study, trying to determine what is valid, sensible, and useful in light of the realities of everyday practice and the concrete particularities of the clinical situation. In accord with the values of pragmatic thought, however, we avoid rigid or reductive application of research findings, treatment guidelines, or protocols. In the following chapter we explore non-reductive versions of materialism that allow us to think of ourselves as physical beings without reducing mind and meaning to the dynamics of brain activity.
We rediscover the crucial importance of humanistic values at a time when renderings of help and care are shaped largely by' a technical rationalism and reductive models of evidence-based practice. The humanities help us consider fundamental concerns in the clinical situation, enlarging ways of seeing, understanding, and acting. The liberal arts challenge the abstractions of theory' and the generalizations of empirical research, enriching our faculties of reflection, imagination, emotion, and empathy, strengthening our capacities to negotiate the irreducible ambiguities, complexities, ironies, and inconsistencies of human experience.
The thinkers who shaped the emerging field of psychotherapy at the turn of the 20th century' came to see the humanities as a foundation of clinical training, emphasizing the way's in which literature, mythology', and the aits deepen our appreciation of fundamental concerns in the human situation, challenging practitioners to consider questions of meaning and purpose, agency and will, freedom and justice, limitation and loss.
The sensibilities that we cultivate through our engagement of stories, novels, poetry, theater, art, music, and film deepen our capacities to negotiate the experience of difference, limits, vulnerability, and suffering as we carry' out our practice, working to recognize and respect the individuality' of the person. The humanities make a world worth living in, as the philosopher Martha Nussbaum observes, where we come to see other human beings as “full people, with thoughts and feelings of their own that deserve respect and empathy” (2010, p. 143). Robert Coles has documented the power of narrative in his moving accounts of adversity' and misfortune, exploring the ways in which stories deepen our understanding of ourselves and the experience of others (1989, 1997, 2010). We come to appreciate the workings of fate, circumstance, and fortune that shape people and lives.
The foundational schools of psychotherapy differ in the philosophical perspectives, root metaphors, narratives, values, purposes, rules, models, and methods that shape training and practice. While we may think of a particular theory' or model of practice as a “first language” or “home base,” we do not privilege any single perspective over other approaches that would potentially' help us address the practical needs of the individual in the given case. There is no single overarching theory. The pluralist perspective allows us to consider the ideas and methods of “purist” thinkers selectively in light of the needs of the clinical situation.
As I show in my accounts of clinical practice in Chapter 9, we may combine ideas and methods from divergent approaches that would be considered incompatible in more pure renderings of the therapeutic endeavor within the foundational schools of thought. From the perspective of clinical pragmatism, there is no single criterion or authorized method that can be used to determine the validity' of a therapeutic construct; there is no universal measure of its success (Borden, 1994, 2009, 2010, 2014).
We assume that beneficial outcomes follow from attuned and flexible use of different ideas and methods across the schools of thought. In following a clinical pragmatism, as we will see, we think of psychotherapy' as an open practice that is governed by our capacities to make use of different elements, experiential learning, and concrete outcomes rather than by fixed commitments to particular theoretical perspectives, empirical findings, or technical strategies per se. We realize that one approach may be more helpful than another at different points in the therapeutic process.
The therapeutic experience demands a richer vocabulary’ than any single theory' or model can give it. Embracing the virtues of theoretical pluralism, Jerome Frank emphasizes the crucial functions of heuristics that provide plausible explanations of problems in living and the core activities believed to foster change and growth over the course of help and care. As we will see, the science of mind and the foundational schools of thought offer theories that help therapists and patients make sense of what is the matter and what carries the potential to help. They provide plausible explanations of problems in living and the way's in which core activities of the therapeutic process bring about change and growth. Cogent and coherent explanations of problems in living and the rationale of therapeutic activities strengthen morale, self-efficacy, and mastery' (Frank & Frank, 1991; Wampold, 2010; Wampold & Intel, 2015). Although the dominant world views of particular cultures shape our perceptions of the authority' and plausibility' of different therapeutic rationales and practices, our notions of what makes sense are also influenced by personality' and temperament, values and sensibilities, and earlier experiences of help and care; professional training, group identities, and institutional loyalties; reason and empirical evidence; and the possibilities and constraints of the clinical situation.
While no particular theory' or heuristic appears to be empirically superior to any' other, Frank emphasizes that the patient and the clinician must believe in the potential value of the approach they' have taken. And, as Bruce Wampold points out in his discussion of common factors, there is empirical support documenting the crucial importance of our belief and faith in the efficacy and effectiveness of the theories and methods we engage over the course of the therapeutic process (Wampold, 2010, p. 110). Researchers continue to explore the neurophysiological processes that mediate the beneficial effects of belief, faith, and hope (for reviews of research on the magnitude of the placebo effect see Cozolino, 2017, and Sternberg, 2009).
Reflection-in-Action, Experiential Learning and Practical Outcomes
Following Dewey, we think of doing and knowing as indivisible aspects of the same process, and we call upon opportunities for experiential learning within the therapeutic process itself as well as in the relationships, activities, and surrounds of everyday life. We embrace pragmatic formulations of ideas as tools for thinking, drawing on different perspectives in light of changing needs, capacities to make use of various elements, and emerging concerns over the course of the therapeutic process. We carry out “experiments in adapting to need,” moving from the possible to the workable, judging the validity of differing approaches in light of their “cash value.”
Donald Schon, drawing on Dewey’s notion of learning by doing, challenges conceptions of “technical rationality” that represent practitioners as instrumental problem-solvers who select technical means best suited to particular purposes on the basis of empirical findings (1983, 1987). He introduces the notion of “reflection-in-action” in his efforts to capture the dynamics of skilled practice, emphasizing the clinician’s ongoing reflection and appraisal of evolving conditions and circumstances in a rapid, implicit, holistic fashion. In his account of professional excellence, the practitioner frames the “problematic situation,” selecting particular concerns for attention, guided by an assessment of conditions and circumstances that brings coherence and direction for action; he describes it as an “ontological process”—“a form of worldmaking,” in the phrase of Nelson Goodman (1978, p. 36).
In accord with Dewey’s formulations of interpersonal collaboration, Schon reaffirms the crucial role of “reflective conversation” between the practitioner and the patient that facilitates revision of understanding and action in light of evolving outcomes. Following the idiographic perspective introduced earlier, we recognize the unique nature of the therapeutic process and realize the limits of systematic practices delivered in a standardized manner. Experiments in adapting to need take precedence over notions of efficiency. Above all, as Dewey observes, a pragmatic intelligence is a “creative intelligence, not a routine mechanic... intelligence frees action from a mechanically instrumental character" (1917, pp. 63-64, italics added). The clinician must consider a range of approaches in the search for what will be facilitative in the given moment.
As I have emphasized, the therapeutic process is guided by what proves useful rather than by fixed commitments to theoretical systems, empirical findings, or technical procedures. Pragmatism validates the authority of our experience. As Menand observes, it encourages us to trust our own judgments—to have faith that if we do what is right, the rest will follow (1997, xxxiv).
Researchers have documented the efficacy and effectiveness of psychotherapy over the last half century, and we have come to think of therapeutic practices as powerful forms of help, care, and healing. As decades of studies show, the benefits of psychotherapy are considerable. Meta-analyses of outcome research demonstrate the effectiveness of treatments across a range of diagnostic conditions, populations, and settings.2 A variety of approaches developed in the foundational schools of thought earn- the potential to help patients reduce symptoms, reinstate healing processes, strengthen coping capacities, and improve interpersonal functioning. Patients deepen understanding and develop skills over the course of therapy that they continue to engage after treatment has ended, maintaining gains and strengthening capacities (for reviews and analysis of efficacy and effectiveness research see Kazdin, 2007; Lambert, 2013, 2015; Shedler, 2010, 2015; Solms, 2018; Wampold, 2010; Wampold & Intel, 2015).
We know that psychotherapy works. From the start of research on therapeutic practice, however, clinical scholars have differed in their beliefs about the particular factors thought to account for change and growth over the course of care.
In a seminal paper that pointed to the general equivalence of different approaches, published in 1936, Saul Rosenzweig proposed that all forms of psychotherapy share basic elements that account for their effectiveness. Beyond the particular beliefs and methods associated with different approaches, he argued, “there are inevitably certain unrecognized factors in any therapeutic situation” that may be “even more important than those being purposely employed” (Rosenzweig, 1936, p. 412). In his account of core elements he emphasized the crucial functions of the therapeutic relationship and the role of theoretical formulations that provide plausible explanations of problems in living and curative factors over the course of treatment. He called upon Lewis Carroll’s Alice in Wonderland in his formulation of the dodo bird verdict: “At last the Dodo said, ‘Everybody has won, and all must have prizes’” (1936, p. 412).
Jerome Frank drew on Rosenzweig’s contributions in developing his conceptual framework for psychotherapy, focusing on the functions of the therapeutic relationship, the social and cultural contexts of healing practices, conceptual schemes that provide cogent explanations of problems and therapeutic interventions, and core activities that strengthen morale, mastery, capacities, and skills (Frank & Frank, 1991). According to the common factors perspective, we assume that therapeutic approaches exert their effects largely through core processes that operate independently of technical procedures associated with particular schools of thought.
Other researchers challenge this view, however, believing that we will come to identify specific factors that account for the relative effectiveness of particular approaches. The “specificity hypothesis” has guided efforts to establish a technical eclecticism in the domain of evidence-based practice. Briefly, the goal is to match specific methods of intervention with circumscribed problems in functioning on the basis of empirical findings and clinical knowledge. In a prescriptive version of this approach, clinicians use standardized treatment protocols linking diagnostic categories and technical procedures that they seek to validate in randomized controlled clinical trials.
We find some evidence that certain techniques are potentially more effective than others in the treatment of circumscribed symptoms, and some studies suggest that the beneficial effects of cognitive-behavioral approaches tend to decay over time. Overall, however, there is currently no convincing evidence that one approach is better than another for the wider range of problems in living that clinicians address in the day to day practice of psychotherapy (Lambert, 2013; Shedler, 2015; Wampold, 2010; Wampold & Intel, 2015). At this point, metaanalyses of research attempting to determine the relative efficacy of differing therapeutic approaches continue to show that all are roughly equally effective, supporting theory-driven approaches across the foundational schools of thought, documenting common effects across treatments. These findings challenge conceptions of psychotherapy that posit specific treatment effects for specific disorders, pointing to the crucial role of common factors and core activities rather than technical procedures in determining outcomes (Lambert, 2013; Norcross & Wampold, 2018; Shedler, 2015; Wampold, 2010; Wampold & Intel, 2015).
It is possible that unexamined assumptions and the nature of the methods that have shaped research thus far have limited our ability to determine whether significant differences do exist across different approaches, and continued study may yet document the strengths of particular models or techniques. Shedler speculates that the Dodo bird verdict may reflect a failure of investigators to consider the wider range of phenomena engaged over the course of the therapeutic process (2010).
Even so, the single-mechanism theories of therapeutic action set forth in purist models of practice fail to reflect the wider range of conditions and processes that are likely to account for the beneficial outcomes we find across divergent forms of treatment. Drawing on the orienting perspectives of neuroscience and the outcomes of psychotherapy research, it is reasonable to assume that change and growth occur through multiple mechanisms of therapeutic action, each of which may be engaged by different techniques.
In reformulating concepts of therapeutic action, clinical scholars reaffirm the fundamental role of core processes that are likely to be helpful for all patients as well as particular techniques that may be useful for some and not others. As Frank explains, the core activities of divergent forms of psychotherapy serve basic functions thought to foster change and growth. They challenge our experience of demoralization, helplessness, and hopelessness by strengthening the therapeutic relationship and collaborative alliance, creating expectations of help, offering new learning experiences, intensifying emotion, deepening a sense of efficacy and mastery', and generating opportunities for practice of new behaviors (Frank & Frank, 1991, p. 44). In light of our differing capacities to make use of particular approaches and methods, however, we realize that certain forms of therapeutic action may be more or less useful in the given case (see Chapter 9; also Borden, 1998, 2014; Gabbard & Westen, 2003; Kazdin, 2007).
In accordance with the principles and values of the pragmatic approach I have outlined here, the ways in which the therapeutic process is carried out are more important than the particular theoretical perspective, model of intervention, or technical procedure. As we have seen, pragmatic conceptions of help and care emphasize fundamental concerns that are likely to determine outcomes on the basis of the research evidence and clinical experience: the crucial importance of our focus on the person as an individual and subjective domains of experience; the core conditions of the therapeutic relationship, the collaborative alliance, open-ended dialogue, and the dynamics of interactive experience; pluralist approaches to understanding that offer plausible ways of formulating what is the matter and what carries the potential to help, strengthening a sense of hope and expectation; varied opportunities for experiential learning, fostering a sense of mastery and development of capacities and skills; and ongoing assessment of progress and outcomes over the course of treatment. The test for pragmatic knowledge is whether it effectively guides actions that bring about intended results in the given case.
We sometimes speak as if the question of what is therapeutic can be resolved by empirical research. It is an empirical question, but it is one that we can answer only in the concrete particularity of the given case. Our evaluations of therapeutic outcomes are shaped by differing concerns and problems in living, goals and expectations, values and worldviews. Life is not a controlled clinical trial, and we cannot know in advance how we will come to understand what is the matter or how we will make use of different elements over the course of the therapeutic experience. As Caro Strenger reminds us, we find ourselves working in a profession that will never be able to rely on algorithms to guide the ways we carry out our practice (1997, p. 144).