AHMAS

Note: Reprinted from “Some Implicit Common Factors in Diverse Methods of Psychotherapy,” by Saul Rosenzweig, 1936, American Journal of Orthopsychiatry, 6, pp. 412–415. Copyright 1936 by the American Orthopsychiatric Association, Inc. Reprinted by permission.

“At last the Dodo said, ‘Everybody has won, and all must have prizes’.”

It has often been remarked upon that no form of psychotherapy is without cures to its credit. Proponents of psychoanalysis, treatment by persuasion, Christian Science and any number of other psychotherapeutic idealogies can point to notable successes. The implication of this fact is not, however, univocal. The proud proponent, having achieved success in the cases he mentions, implies, even when he does not say it, that his ideology is thus proved true, all others false. More detached observers, on the other hand, surveying the whole field tend, on logical grounds, to draw a very different conclusion. If such theoretically conflicting procedures, they reason, can lead to success, often even in similar cases, then therapeutic result is not a reliable guide to the validity of theory.

It takes but little reflection to arrive at the roots of the difficulty from the standpoint of logical deduction. Not only is it sound to believe that the same conclusion cannot follow from opposite premises but when such a contradiction appears, as seems to be true in the present instance, it is justifiable to wonder (1) whether the factorsalleged to be operating in a given therapy are identical with the factors that actually are operating, and (2) whether the factors that actually are operating in several different therapies may not have much more in common than have the factors alleged to be operating.

Pursuing this line of inquiry it is soon realized that besides the intentionally utilized methods and their consciously held theoretical foundations there are inevitably certain unrecognized factors in any therapeutic situation—factors that may be even more important than those being purposely employed. It is possible for the procedures consciously utilized by the therapist to have a largely negative value in distracting attention from certain unconscious processes by means of which the therapeutic effect is actually achieved. Thus it might be conceivably argued that psychoanalysis, for example, succeeds when it does, not so much because of the truth of the psychoanalytic doctrines about genetic development but rather because the analyst, in the practice of his method, quite unwittingly allows the patient to recondition certain inadequate social patterns in terms of the present situation—a phenomenon better explained by Pavlov's than by Freud's theories. Granting for the purpose of argument that this is the case, then the concepts of Freud are far less proved true by the successful analysis of a patient than are those of Pavlov—and the therapeutic result achieved cannot uncritically be used as a test of theory advanced!

While this negative conclusion may be satisfying in some measure, it fails to solve the problem inherent in the fact from which it was derived. What, it is still necessary to ask, accounts for the result that apparently diverse forms of psychotherapy prove successful in similar cases? Or if they are only apparentlydiverse, what do these therapies actually have in common that makes them equally successful? In undertaking to answer these questions, it will be assumed for purposes of exposition that all methods of therapy when competently used are equally successful. This assumption is not well-founded, for certain forms of treatment are very likely better suited than others to certain types of cases. For the present, however, this likelihood, as well as the related problem of determining the criteria for applying one method rather than another to a given patient, will be intentionally disregarded.

In seeking the factors common to diverse methods of psychotherapy the foregoing discussion of implicit procedures should be recalled. Such unverbalized aspects of the therapeutic relationship as were there illustrated by the concept of social reconditioning may be equally represented in therapies of quite dissimilar guise. The possibility for catharsis constitutes another example of the same sort. With such potent implicit factors in common, externally different methods of therapy may well have approximately equal success.

Very closely related to such implicit factors is the indefinable effect of the therapist's personality. Though long recognized, this effect still presents an unsolved problem. Even the personal qualities of the good therapist elude description for, while the wordsstimulating, inspiring, etc., suggest themselves, they are far from adequate. For all this, observers seem intuitively to sense the characteristics of the good therapist time and again in particular instances, sometimes being so impressed as almost to believe that the personality of the therapist could be sufficient in itself, apart from everything else, to account for the cure of many a patient by a sort of catalytic effect. Since no one method of therapy has a monopoly on all good therapists, another potentially common factor is available to help account for the equal success of avowedly different methods. From the standpoint of thepsychological interpretations given by therapists of different persuasions, another partial solution of the present problem may be offered. If it is true that mental disorder represents a conflict of disintegrated personality constituents, then the unification of these constituents by some systematic ideology, regardless of what the ideology may be, would seem to be sine qua non for a successful therapeutic result. Whether the therapist talks in terms of psychoanalysis or Christian Science is from this point of view relatively unimportant as compared with the formal consistency with which the doctrine employed is adhered to, for by virtue of this consistency the patient received a schema for achieving some sort and degree of personality organization. The very one-sidedness of an ardently espoused therapeutic doctrine might on these grounds have a favorable effect. Having in common this possibility of providing a systematic basis for reintegration, diverse forms of psychotherapy should tend to be equally successful.

From a somewhat different approach, though still under the general heading of interpretation, another notion contributing to the solution of the problem suggests itself.

There are several stops in the argument. In the first place, psychological events are so complex and many-sided in nature that they may be alternatively formulated with considerable justification for each alternative. Under these circumstances any interpretation is apt to have a certain amount of truth in it, applying at least from one standpoint or to one aspect of the complex phenomenon being examined. Hence it is often difficult to decide between various interpretations of the same psychological event; they are all relevant, though perhaps to a greater or less degree, and are all therefore worthy of some consideration.

In the second place, personality seems to consist in anindependent organization of various factors, all of them dynamically related.  It is impossible to change any significant factor or aspect of this organization without affecting the whole of it for it is all of a piece. If this description is correct, it follows that in attempting to modify the structure of a personality, it would matter relatively little whether the approach was made from the right or the left, at the top or the bottom, so to speak, since a change in the total organization would follow regardless of the particular significant point at which it was attached.

If, now, a given method of psychotherapy represents but one alternative formulation of the problem presented, it does not need to be completely adequate from every standpoint and may still betherapeutically effective. It needs to have merely enough relevance to impress the personality organization at some significant point and so begin the work of rehabilitation. The interdependence of the personality system will communicate this initial effect to the totality. This line of reasoning would, if true, considerably decrease the therapeutic importance of differences in psychological interpretation and so once more contribute to the explanation of how allegedly diverse methods of psychotherapy prove to have about equal success.

In conclusion it may be said that given a therapist who has an effective personality and who consistently adheres in his treatment to a system of concepts which he has mastered and which is in one significant way or another adapted to the problems of the sick personality, then it is of comparatively little consequence what particular method that the therapist uses. It is, of course, still necessary to admit the more elementary consideration that in certain types of mental disturbances certain kinds of therapy are indicated as compared with certain others.

Were the problem of psychotherapy being considered in detail here, an attempt would be made to show that the therapist should have a repertoire of methods to be drawn upon as needed for the individual case. It would also be important to discuss the intricate psychodynamics of the relationship between the personality of the patient and that of the therapist in order to determine whether a particular sort of patient would not get along best with a therapist having a particular sort of personality. Even with such additions, however, much room would be left for the foregoing general argument based upon the following considerations which apply in common to avowedly diverse methods of psychotherapy: (1) the operation of implicit, unverbalized factors, such as catharsis, and the as yet undefined effect of the personality of the good therapist; (2) the formal consistency of the therapeutic ideology as a basis for reintegration; (3) the alternative formulation of psychological events and the interdependence of personality organization as concepts which reduce the effectual importance of mooted differences between one form of psychotherapy and another.

Specific techniques, such as hypnotism, fall outside the intended scope of the present brief discussion. Only such forms of psychotherapy as are based upon a general theory of personality are here being examined.

 It is by no means being overlooked that there is another far more pressing problem which these notes do not consider—how it is that in so many cases all methods of therapy prove equally unsuccessful.

 The interdependence of the factors is not incompatible with their “disintegration,” as may at first glance appear, since factors that are inharmoniously related (“disintegrated”) are nevertheless related within the given individual in some measure. The notion of conflict bears out this statement.

⁴ Thescientific adequacy of the theory of personality upon which a method of therapy is based is quite another matter. It is, moreover, not at all implied that a more scientifically adequate theory of personality would not give rise to a more effective method of psychotherapy, now or in the future. The point is simply that complete or absolute truth is by no means necessary for therapeutic success.