Chapter 27 |e native approach to 58, 182-208. 3 logy: Toward an ethic of 2 of values in psychology’ 1 (64s), The intrprotive University Press. tion: An analysis ofthe 4 {forthe Theory of Social ‘wet pendant la vielease: ceasons for an old educa- &LR Trunk, Tans), 3) ) Freadianism: A extical ‘hed 1927) ‘bridge: The MIT Press. 1. Bds), Mind in soctets: ‘vard University Press, G, The concept of acti MA: Harvard University hild development today ct - Cambridge, Ma: + account ofthe genesis ‘cation, and cognition: 1, Mitchel 6). Om 1 style lventre. The Sc. Journal of Moral dlalgue in education 4 edit. New York. Joh. 1 dissertation, Boston CHAPTER 28 Adult Development and the Practice of Psychotherapy MicHaEL BASSECHES This chapter explores the implications of the field of adult development for the practice of psychotherapy. The study of adult development has transformed developmental psychology from the study of child development into a lifespan developmental psychology, now capable of offering a viable alternative frame of reference for psychotherapy practice to traditional conceptual frameworks rooted in the fields of psychiatry and clinical psychology. This chapter asks: In what ‘ways does using lifespan developmental psychology as one's primary conceptual frame of reference lead to differences in approaches to psychotherapy practice with adult clients, and/or to the training and supervision of adult psychotherapy practitioners? The eight major sections that follow consider implications of thinking about the practice of psychotherapy in developmental terms for conceptualizing ) the goals, values, and philosophical justification of psychotherapy practice {in general; (2) the availability/accessibility of psychotherapy—that is, whom psy- chotherapy is for; (3) the nature of therapeutic processes; (4) the relationships and differences among various theories and techniques employed by therapists; (5) formulations of clients’ psychological functioning, including implications for therapeutic goals and approaches for specific clients; (8) the psychological functioning of therapists, including implications for their role in the therapeutic Processes; (7) why psychotherapy sometimes fails; and finally (8) the training and supervision of psychotherapy practitioners. The chapter concludes with con- sideration of issues regarding the integration of clinical with developmontal perspectives. These issues are important in the psychotherapy practices of G) therapists initially trained in clinical models who want to integrate insights from the field of adult development into their practice, (2) therapists initially trained in developmental models who practice psychotherapy within the ‘broader social context of “providing health services,” and (3) therapists trained in eee ‘Moca Bassecaes © Bureau of Study Counsel, Harvard University. Carabridge, Mansechuaets, 02138, Handbook of Adult Development. edited by J. Demick and C. Andreoletti. Plenum Press, New York, 2002 533ssa (Chapter 28 qilinical-devolopmental” psychology understood as a subdiscipline “involving the application of developmental considerations...to clinical problems and/ee processes” (Demick, 1996, p. 13). In focusing on what the field of adult development has to offer to the practice of psychotherapy, this chapter places in the background the equally important question of what the practice of psychotherapy has to offer to the field of adult development. Addressing this latter question entails comparing psychotherapy with such “natural” contexts as workplaces, families, and social networks in which adults develop, as well as with such practices as adult education, whi may represent deliberate systematic efforts to foster adult development. While developmentally oriented adult education can be understood as an effort to create ‘more optimal conditions for the development of large numbers of adults than their more “natural” environments, taken by themselves, provide, psychotherapy Practices can be understood as efforts to create more optimal conditions for the development of individual clients. In effective psychotherapy, as in effective adult education, the developmental curriculum is often drawn largely from life Challenges faced by adults outside the setting, but also in part created by con tions built into the structure of the setting itself. This chapter offers discussion of how psychotherapy fosters development, as well as how developmentally or ented therapists conceptualize the nature of clients’ developmental curricula, icit dis of the relationships among therapy, pmental curricula, the reader is referred to the work of Kegan (1982, Ch. 9; 1994, Ch. 7) and Basseches (1984, Part IV; 1989b, pp. 43-44). IMPLICATIONS OF CONCEPTUALIZING PSYCHOTHERAPY DEVELOPMENTALLY ‘The Goals, Values, and Philosophical Justification of Psychotherapy Practice Not all lifespan developmental psychologists are genetic epistemologists in the tradition of Jean Piaget (1972). Fifteen years ago (Basseches, 1984), as the field of adult development was burgeoning, 1 presented research and analysis that offered a case both for the possibility of transforming genetic epistemology into ‘an adequate basis for the study of adult development as well as child develop. ‘tient, and for the importance of maintaining the following clear conceptual dis- tinction within the rapidly expanding adult development field. This is the distinction between (1) studies clearly building on a conception of development that, like Piaget's, entails more complex organization and increased epistemic adequacy, and (2) studies that may employ the term “development” in their con. Ceptualization, but that are presented in ways that the term's philosophical sig. nificance is lost (or worse, where its positive connotations are stolen, without any Philosophical justification provided). This section highlights the contrality of this distinction to the question of whether work in adult development provides a framework with adequate philosophical underpinnings, or merely a tool, for psychotherapy practice.(Chapter 28 scipline “involving al problems and/or. offer to the practice » equally important © the field of adult ting psychotherapy § social networks in # education, which evelopment. While 1s aneffort to create 4ers of adults than ide, psychotherapy | conditions for the ipy, as in effective mm largely from life t created by condi- offers discussion of velopmentally ori- pmental curricula. >s among therapy, | vereader is referred es (1984, Part IV; epistemologists in 1984), as the field and analysis that epistemology into as child develop- ar conceptual dis- Seld. This is the ‘n of development steased epistemic tent” in their con- ohilosophical sig- olen, without any the centrality of lopment provides merely a tool, for ‘Adult Development and Peychotherapy 535 ‘The present volume is evidence of the degree to which the expansion of the eld of adult development has indeed continued over the past 15 years. I hope that in the course of this expansion, this key distinction hes been clarified rather than lost. I expect that this volume reveals both increased appreciation of how developmental change (in the sense of construction of more complex, epistemi- cally adequate forms of psychological organization) may occur in adulthood, as well as increased appreciation of many other psychological changes that tend to occur in adulthood, but that may or may not be developmental. hope that my co- contributors to this volume collectively succeed in the increasingly challenging task of clarifying the distinction and relationships between these two rich bodies of work. For the practice of psychotherapy, the broad spectrum of research on adult- hood may provide useful information, but it is what I call the “dialectical constructivist” approach that offers a significant philosophical alternative to the “clinical” justification of the practice. I refer interested readers elsewhere {Basseches, 1997a) for a fuller exposition of this approach. Here, I try to spell out how its view of the underlying goals, values, and justification of psychotherapy contrasts with the medical model in which conceptual frameworks as varied as psychoanalytic theories, cognitive-bohavioral theories, and family systems theories have common roots. Dislectical-constructivists understand development as a process of resolving conflicts which occur in experience through the construction of “novel synthe: ses” (Pascual-Leone, 1990) that reorganize conflicting activity schemes and repre- | Sentational schemes. The conflicts may be intrapsychic (among one individual's | schemes) or interpersonal (actions organized by one person's schemes evoke | negative, unanticipated, or disconfirming responses from others, whose activity is } onganized by their action and representational schemes). Novel syntheses that represent development entail increased differentiation and integration, in that they maintain previously existent capacities and meanings but have now reorgan- ized those capacities and meanings in ways that take account of and resolve the conflict among them. They entail increased epistemic adequacy in that they facilitate adaptation to (assimilation and accommodation of) a broader range of Worth tn pach onccnton” by ni hn “coputve cpio thug tn tee eptacogl ppt, eyes Kndononay ee ee cffsine gain anderond ate eguiaton ef el nance cael os eae SrptonatonlKaowsig ir andnondvetin oes ocean a ee a Tvl item cage prope eftaowllgrsmactee detvol ins hes sree try petenng tas orpnetonl hanton (atta, use eer aah ta ine) Mythic owing tamed ox mestng Coa ao ae Teen copie organo oxcaig ereeed mac ea ma Ing sch nt Ea te ltestip Berane eee ea fn creel onus on ures 0008 pe ee ea tralology endorsing In gg he op tnwene drcopasneneet ne ee prc) Hoge (07) fot deat seu te eronsegea een se ey nrc: Howoor, [le nce as fe aly ek eat ee elope rvbege 18) swell yous og, so erens malts Wan aot ee Oks taba clr that hy equate develope wis nee a a ae) lel a ppcosoda yan thou! enpcly speing Se mie ‘eEaingtdoviedgy me wie he pda536 (Chapter 28 ‘experience (data), and, in the case of interpersonal conflict, increase intersubjec- tivity and correct for egocentric and ethnocentric biases via the differentiation and integration of multiple perspectives. As a foundation for psychotherapy, a dialectical-constructivist perspective on adult development makes development the primary goal of psychotherapy with adults. The primary value that should guide both therapist and client in the work of psychotherapy is the value on the construction of more differentiated and integrated, epistemically adequate organizations of experience, action, and mean- ing, which represent adaptations to the experiential challenges that bring a client to therapy and that emerge in the therapy process. Psychotherapy is justified inso- far as it provides resources that supplement those clients find in themselves and their life circumstances for resolving the intrapsychic and interpersonal conflicts that they experience. Within the medical model of psychiatry and clinical psychology, many con- ceptual frameworks also emphasize the importance of intrapsychic and interper- sonal conflict, However, the medical justification of psychotherapy, like other medical interventions, is either pain or abnormality. Psychotherapy is justified as, an effort to remove the distress and abnormality, which are usually manifest in the form of “symptoms.” Thus, within a medical model, the goal of psychotherapy is the removal of symptoms of distress and abnormality. Even if symptoms are conceptualized as reflections of underlying “peychopathological” processes, and. clinically oriented practitioners wam that it is the underlying disease process, rather than the specific symptoms that should be targeted, “psychopathology” can ultimately be judged only by observable experiences of distress and difference. Regardless of whether the focus of treatment is specific symptoms or the underly- ing processes that are presumed to generate symptoms, viewing psychotherapy as a clinical intervention implies that the values that should guide the therapist and client in their work are the ideals of freedom fom suffering and conformity to “normality.” ‘The monitoring of psychotherapy by outside managers brought by the era of “managed care” has made the aforementioned features of the medical model more vivid in the accompanying demands upon psychotherapists for symptom-focused assessments, treatment plans, and progress reports. However, in making these requests, and attempting to monitor the effectiveness of psychotherapy more sci- entifically, these managers are only building on assumptions of the model that \ were present when most practitioners were trained within a medical or clinical | model of psychotherapy. Psychotherapists who don’t like this intervention are | forced to either confront the inadequacy of the model, or else attribute their dis- mfort to a reluctance to have their work systematically monitored by outsiders. This discomfort is just one of several challenges to the clinical conception of the underlying goals, values, and justification of psychotherapy practice, which should make the developmental alternative appealing. While some of the chal- Jonges arise from the discomforts (e.g,, with managed care) of psychotherapists who were themselves initially trained as clinical psychologists, psychiatrists, and clinical social workers, others have been posed from the developmental per {SBective. Whereas the medical model justifies psychotherapy ultimately by } appeal to the value of “health,” the developmental model justifies psychotherapy ultimately by appeal to the value of a human developmental process that can beChapter 20 J crease intersubjec- the differentiation lotivist perspective 1 of psychotherapy ist and client in the | e differentiated and " + action, and mean- s that bring a client (py is justified inso- in themselves and personal conflicts chology, many con- yohic and interper- therapy, like other 4 srapy is justified as ally manifest in the lof psychotherapy ‘n if symptoms are zal” processes, and 1g disease process, chopathology” can oss and difference. ms or the underly- 3 psychotherapy as e the therapist and and conformity to ought by the era of edical model more symptom-focused + in making theso therapy more sci- of the model that nedical or clinical s intervention are attribute their dis- cored by outsiders. ‘ical conception of oy practice, which some of the chal- ’ psychotherapists ists, psychiatrists, evelopmental per- py ultimately by ies psychotherapy rocess that can be Adult Development and Psychotherapy 337 {viewed psychologically as ego development, biologically as intelligent adapta- Ltion, and epistemologically as truth-seeking (Kegan, 1982, p. 294). From a per- spective shaped by this latter primary value, the operations of the norms of health in the “mental health” sphere appear suspect in a couple of ways, First of all, the equation of psychological discomfort with ill health is prob- lematic. It is epistemologically adaptive—in the service of the search for truth—for cognitive disequilibrium—a yet-to-be-resolved conflict among meaning-making structures or between expectations and experience—to be experienced psycholog- _Acally as discomfort. Such discomfort motivates directing attention to the resolu- | tion of the conflict, While a developmental justification of psychotherapy affirms ‘the developmental value of both the encounters with conflict that create discom- Hort and the resolutions of such conflicts that may evoke moro felt satisfaction, a | clinical justifcation of psychotherapy would only affirm the value of the resolu- | tion of conflict, and might equally affirm the avoidance of conflict or any other approach to reducing psychological discomfort (e., the use of medication). Now, in fact, many practicing psychotherapists would personally affirm the value of their clients facing conflict rather than avoiding conflict. However, to reconcile this value with the clinical perspective, they are required to make the case that fac- ing the conflict will result in less discomfort forthe client in the long run—e case \ that is often difficult to support based only on psychological theory and extant }data. 1 suggest such therapists would be on firmer ground if they conceptualized their practice primarily using developmental models, rather than clinical ones. The equation of mental health with “normality” is equally problematic. From | the perspective of a value on truth-secking, therapists’ judgments of what conduct } and experience constitutes mental health and what constitutes “deviance” or J “psychopathology” are suspect as arbitrary or ethnocentric. Such judgments must ultimately appeal to some combination of what is statistically normative and to the shared norms of acceptability of those who are deemed mental health experts. ‘The history of American clinical psychology and psychiatry’s treatment of homo- sexuality vividly illustrates this problem. Whereas homosexuality formerly was viewed as a disorder—a form of psychopathology—to be treated (American Psychiatric Association, 1968), homosexuality now is viewed officially as a men- tally healthy alternative, although “persistent and marked distress about sexual orientation” may be treated (American Psychiatric Association, 1994). Yet it is difficult to trace this change to any statistical change regarding the prevalence of homosexuality. Rather, the change appears to be the result ‘of a sociopolitical process. Whereas formerly the “mental health” community sided with other American communities (e.g., “the religious right,” “the business establishment,” “major league professional sports,” etc.) in excluding and devaluing members of the gay community, now members of the gay community have sufficiently effec- tively organized themselves and entered and influenced the mental health com- munity to bring about a change in the latter’s official platform, much as they have influenced the platform of a major political party. if “mental health experts’” judgments aro so arbitrary and subject to the sociopolitical winds blowing in their community and to the constitution of their membership, it is understandable and reasonable for clients to distrust psy- chotherapists who rely on these judgments in guiding their practices. This is a major problem with psychotherapists’ conceptualizing their practices within a538 Chapter28 z clinical frame of reference that depends on reference to what is normal and what abnormal. Alternatively, within a developmental frame of reference, while a j therapist's individual values, or the values of the communities with which the | therapist identifies would be ingredients brought into the therapeutic process (a5 | are the clients’ values), only the interrelated values on epistemic adequacy and |_ development would be appropriate as guiding values of the process. It would not ‘he very difficult to make a convincing case that the widespread devaluation of homosexuality and social oppression of homosexuals led to systematically dis- torted communication (see Habermas, 1971) 30 years ago as it does today, and therefore represents an obstacle to the search for truth, This would justify thera- pists’ most diligent efforts to avoid participating in such devaluation and oppres- sion, In contrast, I imagine it would be much harder to make a convincing caso that homosexuality is either mentally healthy or unhealthy. In sum, to approach psychotherapy with a dialectical-constructivist lifespan developmental psychology as a primary frame of reference, is to view psy- chotherapy as a particular form of inquiry and experiential learning, aimed at ‘elopment of more differentiated, integrated, adaptive, and epistemically ade- ‘quate organizations of activity and experience. The conflicts on which the inquiry {focuses are those that the client brings to the inquiry and that arise in the course (of the inquiry. Such an approach is much less vulnerable to many of the internal “Giscomforts and external challenges that therapists who approach psychotherapy primarily within a clinical/medical frame of reference encounter. HEeess AEE e eZee For Whom Is Psychotherapy? Within a primarily clinical perspective, psychotherapy is for clients who suf- fer from some form of mental ill health. The diagnosis of a disorder (abnormality | or suffering) is the justification for treatment designed to restore normality or remove suffering. Within a primarily developmental perspective, psychotherapy represents a set of additional resources which may be brought to bear, in conjunc- tion with clients’ internal and contextual resources. in constructing novel synthe- s that resolve internal and extemal conflicts that clients face. While the next section will detail how these resources may be used, this section considers their availability and accessibility. ‘A developmental perspective implies greater availability and accessibility of psychotherapy. I think that it will be clear from the description of psychotherapy processes to follow, that since everyone faces intemal and external conflicts, ‘everyone could potentially benefit from psychotherapy, understood developmen- tally. On the other hand, to claim within a clinical perspective that everyone has @ psychological disarder that could be treated by psychotherapy would be a reduc- to ad absurdum of the entire frame of reference, which conceives “disorder” in contrast to normal order.? Many therapists attempt to live, however uncomfort- ably, with this absurdity, and proceed to diagnose and treat any individual who earecrum EHO 2Nole, however, thet if one conceives “disorder” developmentally—in contrat to “pesfect orden” rather than eliscally—in contrast to “normal order” tho concept of dsordor i not very iforeat from the coacopt of disequiltriam, which i, arguably, universal experience.Chapter 28 normal and what veference, while a 's with which the peutic process (as nic adequacy and cose, It would not ad devaluation of ystematically dis- it does today, and ould justify thera- tation and oppres- @ convincing case structivist lifespan is to view psy- ‘earning, aimed at epistemically ade- which the inquiry arise in the course any of the internal ich psychotherapy or clients who suf order (abnormality store normality or ve, psychotherapy obear, in conjunc- :ting novel synthe- ze. While tho next on considers their and accessibility of 1 of psychotherapy extemal conflicts, stood developmen- ‘hat everyone has a would be a reduc- ‘ives “disorder” in >wever uncomfort- ay individual who rast to “perfect ordar.” ar isnot very different Adult Development and Psychotherapy 399 conters their offices. Of course, itis not so easy for clients to live with this frame of reference. Becatiso it is necessary to define, even stigmatize, oneself as a person ‘with a psychological disorder to avail oneself of psychotherapeutic resources, itis Tinderstandable ‘that a clinical frame of reference inhibits potential clients from / making use of psychotherapy. fa developmental perspective leads to the conclusion that psychotherapy a potentially valuable resource for all people, rather than a subset of the popula- tion with mental disorders, who should pay the cost of this highly labor-intensive resource? I suspect that some psychotherapists maintain their loyalty to the clint- ‘cal model in the hope of fostering accessibility to psychotherapy through the “parity” argument that health insurance should equally cover mental health costs, so that not only relatively wealthy individuals have access to treatment. (As Tite this, the US Congress has recently failed to agree to legislate such parity) But even if tho parity argument were ultimately to succeed, access would still be limited to those whose conflicts are familiar, abnormal, and painful enough to be diagnosed as disorders. ‘Within the developmental model, the issue of subsidization of psychotherapy costs would be understood in the context of the theory of democracy. The argu- ‘mont that publicly supported education is crucial for democracy (see Dewey, 1916) hhas a much longer and much more successful bistory then the arguments for either ‘universal health insurance or mental health parity. The developmental model sug- gests that the appropriate route to making psychotherapy more affordable through Dublic funding would be the extension of the education-fordemocracy argument to adulthood-—an extension that the field of adult development now makes possi- | blo. Research in adult development that documents the importance of aspects of | adult development to the realization of the ideals of democracy* could be con- I joined with research in adult education that documents how individual, group, | and/or family psychotherapy can most efficiently supplement large-group forms of | Sdult education in successfully fostering such aspects of adult development.* ea ‘The Nature of Therapeutic Processes How does the process of psychotherapy supplement a client's internal and contextual resources in fostering the construction of novel syntheses in response to intrapsychic and interpersonal conflicts? It is important, first of all, to recog- nize that there is great diversity in the practices and procedures employed by the * Habermas (see MoCesthy, 1976) theory of communicative competence and adult development, ia my view, provides the richest etant framework for such researc. 4 As developments in technology facilitate many aspects of adult educetion becoraing les laborSaten- fivera cae for the eficioncy of judicious use of more labor-intensive psychotherapy to address those Sppropriote tothe developmental value of psychotherapy. propote tis might mitigate those aspects ‘Gr managed care which many therapists view as undermining the effectiveness of the process, while ‘il effectively containing its cost Significant portions of the matertal in this section aro adapted (with permission of the publisher) from materia which appeared previously in Basseches (10074).540 Chapter 28 therapists whom adult clionts consult, once the clients enter psychotherapy. This diversity is influenced by the wide range of (1) extant schools of thought ot theories regarding psychotherapy; (2) extant theories or diagnostic frameworks for formulating the nature of clients’ difficulties; (3) popular psychotherapy tech- niques; (4) idiosyncratic aspects of therapists’ personalities, personal styles, and ideas affecting their practice; and (5) training experiences that have affected therapists’ professional development. Psychotherapy outcome research (see American Psychologist, 1996: 5110], for recent summaries and commentaries) ‘suggests that there is indeed great diversity in the ways in which therapists may help clients achieve more successful adaptation, yet it does not demonstrate the clear superiority of any particular approach. ‘The language of a dialectical-constructivist model of adult development offers a frame or motatheory for understanding psychotherapy processes in general that is independent of any therapist's particular theoretical commitments or personal idiosyncracies, The section titled Developmental Perspectives on ‘Therapists’ Psychological Functioning considers therapists’ formal theories within the context of the therapists’ psychological organization as a whole, in assessing the impact of the therapist's development on the psychotherapy process. In this section, this model of adult development is offered to provide a frame for appre- ciating the contributions of a wide range of theories, practices, and therapists’ personal styles to psychotherapy processes, without requiring adoption of the assumptions of particular schools of psychotherapy. [From ¢ dialectical-constructivist perspective, the conflicts that bring clients {to therapy can be understood as resulting from the interaction of limitations and distortions in the meaning-making structures and repertoire of schemes that the clients have developed in prior social contexts and the particular adaptive chal- lenges posed by the clients’ current environments. According to Pascual-Leone (1990), who has integrated adult developmental and nouropsychological perspec- tives in studying the construction of novel syntheses that transcend emotional } conflicts, the key to creating such syntheses is the simultaneous boosting and + maintenance of attention to all of the schemes, structures, and experiences that are in conflict. The prospect of help that psychotherapy offers can be understood to inhere in the various ways that psychotherapy offers additional resources to | Supplement the client's own procesess of attending to and making meaning of his } orher experience. After quoting from Greenberg and Pascual-Leone’s (1995) overview of the role of attentional processes within psychotherapy, I will describe and illustrate three generic psychotherapeutic processes. Each of these processes involves utilizing the unique intimacy of the therapeutic relationship to offer additional resources that make adaptive novel syntheses more likely outcomes of the client's meaning- making efforts. I propose that all effective psychotherapy can be seen as involving some combination of specific forms of these three generic processes. Effective psy- chotherapies may differ from one another both in the specific forms and in the overall admixture of these three generic processes. ‘Altentional allocation isthe centzl processing activity determining people's araroness of ‘hemsoives, What i important for therapeutic purposes is that tention is under both deliberate and automatic control. By using diferent types of interventions at diferent ‘mes, therapists can orient, direct, and monitor cients’ deliberate and automatic attentionChapter 28, psychotherapy. This hools of thought or ‘gnostic frameworks psychotherapy tech- es, personal styles, 2s that have affected come research (see and commentaries) hhich therapists may ‘ot demonstrate the adult development cerapy processes in ‘tical commitments tal Perspectives on mal theories within whole, in assessing apy process, In this ea frame for appre- ces, and therapists’ ‘ng adoption of the ts that bring clients Sof limitatins and of schemes that the sular adaptive chal- 'g to Pascual-Leone chological perspec- anscend emotional xeous boosting and ad experiences that can be understood itional resources to sing meaning of his overview of the role and illustrate three + involves utilizing Aditional resources ve client's meaning- seen as involving :sses. Effective psy- 2 forms and in the 2e's awareness of om is under bot Hons at different somatic atention ae NR enh pias bmg HS ORI ‘Adult Development and Psychotherapy sa {Greenberg ets. 1993), n this way, atuntion provides a medium for change. People can use attention to alter their focus of awareness and to symbolize their inner Personal change then can be achieved in many ways, including the following: (a) by ‘attending to and symbolizing the internal complexity genorated by automatic experience, () by bringing sbout a synthesis of new structures in theropy through coactivation of existing and oewly formed schemes, (c} by generating vital explanations of curently sym- bolized experience, and (d) by restructuring emotional schemes by evoking them and ‘exposing them to new input ‘A dislectical constructiviet perspective therefore yiolds a theory that recognizes the significance of the client's emotional experience as well as his or her cepacity to con ‘struct meaning and develop concepts. This integration implies a view of human beings ‘as muhple-level processors who use different types of propositional (symbolic-logical) {information and atfctvely laden experiential (sensory, perceptual imaginal, nd repre- sentationa) Information. Human beings, in our view, construct representations of them selves and reality in a moment-by-moment fashion, all the while dynamically reacting to ‘hat they are attending to. ‘Thus, growth-promoting conscious experience derives from both deliberetsly controlled (often conscious, serial, and conceptual-representational) procossing of infor. ration and automatic (often unconscious, parallel, and sensorimotor) processing of selfrelevant information. Consequently, an adequate theory should recognize thrve mjor roots of experience: (@) a conscious, deliberate, reflexive, and conceptual process..: an automatic, direct emotional-axperiential process...: and (@) the constructive, ‘inlectica-dynamic interoctions between the two (Greenberg eta, 1993). Reflexive con. cepteal kaowing processes provide explarations, whereas emotional schemes provide ‘immediate reactions, The dialectical synthesis of these difforent sources of experi- \ ence .ultimately leas the person to... psychological maturity. “In therapy, this dialectical constructive process often involves exploring differences {between actual immediate experience and prior conceptually held views of how that experience should be. Contradictions betwoon one’s reflexive or acquired concepts (explanations) about how things are, or ought to be, and one's immediate experience of ‘how things actually are constitute a great source of emotional distete, and these need to ‘be focused on to produce new syntheses that can provide a greater sense of personal coherence. (Greenberg & Pascual-Leone, 1995, pp. 182-104, italics mine) [-77So some schemes and structures may function automatically, activated by ele- / ments ofthe situation, and some schemes and structures may be used deliberately by clionts as they consciously work to make senso of their experience. The view of human experionce italicized above suggests to me that therapists may influencé clients’ attentional, synthesis-secking work by contributing resources to clients’ “conscious, deliberative, reflexive and conceptual processes,” by contributing resources to clients “automatic direct emotional-experiential processes,” and/or by contributing resources to clients’ efforts to bring automatically operating and more deliberately employed schemes and structures into new relationships with each other. The three generic forms of psychotherapeutic action, listed in “Table 28.1, correspond to these three forms of influence. However, I begin with the latter form of influence in my descriptions, because it seems to me most essen- tial and universal within psychotherapy. ‘When psychotherapy is successful, the combination of the processes of providing attentional support, offering interpretations, and participating in the enactment of novel experiences results in clients constructing more adaptive, differentiated, and integrated organizations of their own experience and action repertoires, such that the process of human development can continue to move forward. Ishall now consider these three processes in greater detail.saa Chapter 28 Table 28.1, Three Generic Forms of Psychotherapeutic Action 4 ployment of his or her sstontion in organizing and reorganizing the schemes and structures that consttute his or ber experience, and in addressing his or her adaptive challenges. (Contributes resources to liats! efforts to bring automatically operating and more deliberately employed schemes and structures Snto new relationships with each other) BL INTERPRETATION: Offering additional material fr the client's attention in the forma of novel Linguistic representations ofthe client's experience and its social and physical contexts (i.e, offering interpretations—schemes and structures for understanding that are relevant and wsefel to the client's deliberate conscious efforts to make sense of his or her expecience), and collaborating to verying extents in orgenizing these representations with thove of the client. (Contributes resources to client’ “conscious, deliberative, reexive and conceptual processes”) © ENACTMENT. Greating additional material forthe client’ attention by participating with the ‘ent inthe enactment of novel experiences, thoroby broadening the client's reertene of ‘mumediate experience, while collaborating in efforts to organize and make sease of that, ‘experience, (Contributes resources to clients “automatic direct emotionalexperiontal Processes." Era eH SESPELELELE Forms of Attentional Support. The forms of attentional support that thera- ists offer clients fall into two overarching categories. One catogory of attentional ‘support includes those ways in which the therapist directly assists the client in attending to the full range of tho client's experiences. This facilitates the reorgan- ization of those expertences in ways that help to resolve conflicts and meet adap- tive challenges so that the client's development may continue, The second Category includes ways in which the therapist shares or alleviates the client's bur- den of managing extremoly painful, threatening, or disorganizing emotions, including the panic, anxiety, shame, or senso of isolation, which may be brought on by the subjective experience of failure in the effective maintenance of a coher- ent, adequate organization of activity and experience. Successful establishment of « therapeutic alliance often entails the client feeling less alona in the experience of disorganization, more hopeful regarding a successful resolution of the conflict, and assured that someone else can recognize and respect the integrity of one's personhood, even when one can't recognize it oneself. This frees the client's attention from the sole management of the distress and the crisis of meaning. making failure, and makes more attention available for renewed efforts to mest the adaptive challenges that precipitated the crisis, The fist catogory of forms of attentional support includes such varied there- pist activites as asking clients questions, empathically acknowledging what one has understood clients to be expressing, drawing attention to aspects of clients’ behavior and experience, and reminding clients of experiences that the clients previously described. Such activities represent some of the ways in which thera. pists from a wide range of therapeutic traditions guide and support their clients’ attention to their own experience. Through such activities, therapists boost their Clients’ awareness of aspects of the clients’ own oxperience which they might on their own tend to ignore. Therapists also assist their clients in simultaneously } holding together in consciousness aspects oftheir own experience, behavior, and sonse-making that they might on their own tend to “split” (ie. oaly experience,Chapter 29 ‘yment of his or her & coastitute his or her tes resources to clients’ | schemes and structures ‘in the form of novel vysical contexts (Le, are relevant and useful perience), and "those ofthe client. ‘conceptual processes.") >atticipating with the ent’ repertoire of ke senso of that lexperieatial support that thera- cegory of attentional assists the client in ilitates the reorgan- iots and meet adap- tinue. The second ites the client's bur- ganizing emotions, ich may be brought tenance of a cober- establishment of ¢ in the experience tion of the conflict, @ integrity of one’s 5 froes the client's crisis of meaning- ved efforts to meet such varied thera- wledging what one aspects of clients’ :28 that the clients .ys in which thera- pport their clients’ srapists boost their sich they might on in simultaneously nee, behavior, and », only experience cena ivmemiain ‘Adult Development and Peychotherepy 549 sequentially in different times and/or contexts).® Consider the following interchange:? G:Sick and tired of being told what todo by my mother ‘Really hed it with her meddling in your hie? Yeah, can you belive she called again today to check on whether { was doing my schoolwork? ‘She's just always right there... Kinda Ike you relly dont even get the chance to try facing on your own? Gl smester she wen aout mond witout linge. 7 Is that sadnees Chea in your voice? G: (Starting to cry) Yes, dammit, [felt completely aefl and ended up with two Ds, ‘So you felt badly and you were disappoisted with your gredos? Cf et on my face! just can’ do ton my owa, snd Tam so scared. more crying) So your mother’s checking on you really infirites you, and you are seared Uy What happenad when she left you alone? es Lelly need to prove that Tean succeed on my own, “T Some kind of eacoess is urgent. ‘GT did succeed with my article om the hockay team’s season! My roomate, may English teacher, and some guys frm the team all said they realy 1hed i... And I never told my mothor about thet... And Pia not going to ‘The preceding interchange includes examples of empathically acknowledging named aspects of experience, highlighting underattended-to aspects of experi ence, and bringing together in attention conilicting aspects of experience. Through such processes, conditions are created in which clients can create novel synthetic transformations of their own experience. In the language of dialectics (Basseches, 1984), itis through the affirmation of theses, the discovery of antitheses, and the holding together of theses with their antitheses, that the creation of syntheses occurs. Often, but not always, finding the dialectical tension involves “exploring dif- ferences between actual immediate experience and prior conceptually held views of how that experience should be” as Greenberg and Pascual-Leone (1995, p. 183) describe. This is done by attending to and symbolizing immediate experience and then holding it together with prior constructions, The interchange described in the preceding could easily lead to the client's acknowledging the belief that he or she should have achieved more sense of independence of mother than he or she frequently feels. In turn, accepting that conflict may lead to the client to construct fuller, more complex, more adaptive representations of experiences of both inde- pendence and dependence. The terminology of “guiding and supporting” attention, which allows dis? covery of antitheses and creation of syntheses in experience, is broad enough to describe a fair amount of what therapists who identify themselves as psychody- namic, cognitive-behavioral, existential-humanistic, or in other ways (including “eclectic"), all do, and to relate this activity to the fundamental developmental Processes of the client, Each therapoutic tradition has its own language, and each “Different therapeutic schools use varying language to explain such processes of splitting (e.g, Aefenses, meeting conditions of worth, etc.) However the explanations share a common element {that of contradiction or incompatibility emong the spit of components. “tn the examples that follow, "T” indicates hypothetical comments a therapist might make and “Cr Indicates hypothetiea] responses by a client.5 (Chapter 28 therapist is guided by his or her own theories in guiding and supporting the client’ attention, ‘The second category of forms of attentional support includes activities that are primarily reassuring rather than attention-directive. They support the client's deployment of attention by freeing it rather than by assisting or guiding it. Instead of the therapist joining the client in holding the many aspects of client's problems of conflicts in the attentional field, the therapist holds the client so that the client can more effectively hold the conflicts. If the client feels less alone in his or her experience, attending to even intensely painful feelings may be more manageable. This type of activity was at the core of earlier formulations of “client- centered tharapy" (0.g., Rogers, 1958). Rogers suggested that the therapist's primary job was to provide a climate in which the client experienced “unconditional pos- itive regard," which Rogers believed would then free the client to optimally deploy his or her attention (or “awareness”) in the service of his or her own devel- opment. It is questionable whether so-called “nondirective” responses merely echo the client's expression and communicate positive regard. Insofar as such responses inevitably select particular aspects of the client's communication to reflect, they must play a role in guiding the cliont’s attention as well (Category 1). However, insofar as the principal effect is to reassure the client and to encourage the client's continued efforts to work toward growth, a “nondirective” empathic response may be said to fall into this second category. Clearly, expressions of appreciation of the client's struggle made by therapists of all traditions also fall into this second category. When such appreciation is com- bined with therapist responses which (in any theoretical or diagnostic language) implicitly or explicitly express the therapist’s faith that this form of therapy can help this particular client, the client's panic may be relieved and sense of hopo- fulness fostered. When this occurs, the client's attentional resources are clearly froed to address the task of creating novel syntheses of meaning-making schemes, and therefore such reassuring responses also fall into the second catogory of forms of attentional support. ‘Attontion-freeing responses may range from “mmhmm,” to “I'm here," to “You've tried so hard to let him know how much you're hurting,” to “You have a case of agoraphobia with panic attacks that can be treated successfully in any number of ways.” In sum, development can be understood as an attentional challenge. A wide range of emotion-laden action and experionce schemes, constructed, organized, and reorganized throughout the client’s entire history, and all in some way acti- vated by various aspects of the client's current circumstances or deliberately employed by the client in response to that experience, must again be reorganized in novel and more adaptive ways to enable the client to function effectively and satisfactorily in these new circumstances. A client may be well aware of the func- tioning of many schemes, while other schemes may be functioning with little or no conscious attention, except whon their negative consequences are noticed. The construction of successful novel syntheses will require paying sufficient attention over time to all of the activated schemes and to their relationships to Of couree, this process depends on the clients attributing valid professional authority in the matter ‘to the therapist which does not fallow necessarily from the choice to consult the therapist.(Chapter 23 and supporting the tudes activities that support the client's ‘r guiding it. Instead of client’s problems | nt so that the client alone in his or her e more manageable. alations of “client- "4 Pos: client to optimally is or her own devel- " responses merely 4 rd. Insofar as such communication to swell (Category 2). atand to encourage lizective” empathic made by therapists ppreciation is com- {agnostic languago) orm of therapy can and sense of hope- sources are clearly g-making schemes, d category of forms * to “Tim hore,” to 1g," to "You have a uuccessfully in any challenge. A wide sructed, organized, in some way acti: 1es or doliberately ain be reorganized ion effectively and aware of the func- oning with little or ances are noticed. paying sufficient ir relationships to suthority in the mater the therapist. ‘Adult Development and Psychotherapy m5 one another. Under conditions of crisis, the attentional challenge is even greater, as one's attention is inevitably drawn to those emotionally powerful schemes that are triggered by the experience of grave danger to the overall functioning of the entire organization of the self. While the forms of attentional support provided in psychotherapy vary considerably, they all involve the therapist sharing some of the client’s attentional burden. Offering the Therapist’s Meaning-Making Schemes (Interpretation). Some approaches to therapy rely almost entirely on processes of attentional support (eg., Rogers, 1951). They support the client in mining the developmental possi- bilities inherent in the conflicts that the client experiences, through increasing awareness and holding together of antithetical schemes and structures until novel syntheses are constructed. However, other approaches (0.g., traditional psycho- analysis) offer the therapist's meaning schemes to the client as ingredients of the developmental process. This may facilitate development in a variety of ways. The therapist may offer schemes which are useful to the client in explaining or reorganizing conflicting activated schemes of the client. For example, consider the following exchanges: ‘Tits quite common to long to be close to someone and yet ao to very much fear closeness Well, you know, now thet you mention it, {think thet is exactly what I feel when I 1have boon going ou with someone for quits som time, How do other people deal with ‘hat situation? or “T-My gunss is that wanting to hide your flings of how rauch you like her hos some- thing to do with fear of cont with other men. i did have this really awl droama whore I got best up last night...and in the ater ‘oon Thad bad this thought about buying Sowers for Sandy. ‘The value of the interpretation is realized only once the client is able to make use of it in his or ber own organization of experience. Itis essential for the thera- pist, once offering the interpretation, to go on to collaborate in discovering whether or not it is useful and relevant to the cliont, and if t is useful, how? ‘Alternatively the therapist's schemes may function as the antitheses to meaning-making schemes of the client, and itis in integrating the client's schemes with those of the therapist that development may occur. For example, ‘You told me that you concluded you were powerles to influence things at your daughters school, but in the situation you just described, st sounds to me like you ‘ame across as prety powerful, maybe even scary, to your daughter's teacher (Really? Yseemed scary? 've never thought about myself that way. ‘Tl can see why you might take his offering to do the presentation with you as reflecting lack of confidence ia you, butt occurs to me that he may actually se it as an oppor funy to learn something from you, or maybe to get to know you better. . Well, naybe, but you always haves more optimistic view about these things than ido, “TE. Why do you suppose that is? Again, itis essential that the therapist go on from this point to collaborate in dis- covering whether or not, and how, the therapist’s and client's perspectives can be integrated.Chapter 28 Within the generic developmental model of psychotherapy proposed here, the term “interpretation” is used in a very broad way, not in the particularly psy- choanalytic sense of an account of unconscious dynamics which may underlie _-G@onscious experience. “Interpretation” describes any situation in which thera- pists offer clients their own ways of understanding phenomena—ways of under- standing that differ from or extend beyond the clients’ understanding. Because therapists may differ tremendously among thomselves in the theories they use and in the idiosyncratic ways that they understand human experience, human suffering, the sources of human difficulties, and how they can be ameliorated, interpretations can take very many specific forms. From a dialectical-construc- tivist perspective, the therapeutic value of such interpretations lies in the contti- bution they make to the particular dialectical process that is the client's own, volving organization of his or her life.® Dialogue is a rich source of individual learning and development, and it is the fact thet the therapist has different ways of making meaning from the client that makes psychotherapeutic dialogue possible. Therapists’ formal theories rep- resent part of the therapists’ different ways of making-meaning, and insofar as they contribute to the generation of interpretations that are useful to the client, they may play an important contributory role to effective psychotherapy. Enactments. A client's own past and present experience, and existing ways of organizing that experience, necessarily constitute the bulk of the ingredients out of which novel, more adaptive syntheses are created in therapy. The thera- pist’s attentional support contributes to this creative work. At times, as we have seen in the previous section on interpretations, therapists communicate their understandings and these understandings also contribute to the creative work. ‘The interpretations supplement the mix, serving as additional ingredients which facilitate the creation of new syntheses. However, often what is needed most in the mix of ingredients to increase the likelihood of the client’s creating novel. more adaptive syntheses, is not only new understandings but also new experi- ‘ences, Enactments provide these new experiences, and thereby constitute the third generic psychotherapeutic process. Consider the following example: ‘A.woman, Marla, who was sexually abused asa child, operates on schemes developed out ‘of that experience, and repeatedly partiipetos in new situations in which sbe is abused, {evalued or exploted. She withdraws from relationships, becomes desperstaly lonely, and thea, motivated by ber desperation, enters new exploitative relationships. She views such cxploitetion as an inevitable aspect of intimate relationships, and has well-developed schemes for both creating and escaping from relationships, She describes her experiences {in therapy. Her therapist formulates and offers interpretations of how she may have come "This dialectical constructivist view of therapeutic value contrasts with the tendency of objectivist (see Netmeyer [1993] forthe distinction between objectiviem and constructivism in general) per | Spectives to derive the therapeutic value ofthe interpretation from some notion of accuracy of either | the interpretation itself or the framework from which tho interpretation is decived. It also contrasts with the dialectical-constructivist view of the epistemological value of both interpretations and. feameworks, which lies in the role they play in all ofthe dislectial processes involved in the overall ‘evolving soctal organization of people's interaction with each other and with thelr environment. For ‘the dislectical-constructivst individual meaning raaking dialectics are contributing and interacting ‘components out of which the larger processes of epistemological validation derive, whereas for the objectvis,therepeutic value decives from prior epistemological validity.(Chapter 28 stapy proposed here, «the particularly psy” which may underlie ‘tion in which thera- lena—ways of under- derstanding. Because che theories they use 4 2 experience, human can be ameliorated, dialectical-construc- ons lies in the contri- tis the client's own ‘velopment, and it is ining from the client "formal theories rep- ching, and insofar as useful to the client, ‘chotherapy. ©, and existing ways K of the ingredients therapy. The thera- \t times, as we have communicate their y the creative work. il ingredients which tis needed most in ont’s creating novel, ut also new experi- wreby constitute the ing example: ‘es developed out dich she fs abused, ‘rately lonely, and 15 Sho views such 1s walldevelaped asher experiences vemay have come tendency of objectivist ctivism in gooera) pet- {on of accuracy of either ‘exived. IK also cootraste oth interpretations and + involved inthe overall ‘their environment. For ibuting and interacting derive, whoreas for the ‘Adult Development and Peychotherapy 847 to limiting beliefs that ebuse and exploitation are inevitable aspects of lose relation ships. These interpretations may be useful to her and she may become more aware of and able to conceptualize how her behaviors may contibute to cycles of abuse. Ske may even, be able to entertain intellectually the possibility of excaping such cycles, However, she is likely to lack a repertoire of schemes fr creating and participating in trusting and trust- ‘worthy relationships. Without these schemos, such relationships would likely remain in the reslm of abstract possibility for hec. As Herman (1992), in her work on Trauma and Recovery articulates, it i often through the creation and constant testing of a trusting, relationship with the therapist, that victims of repeated exploitative relationships estab- ish an inital experiential basis for elterastive relational possibilities. Its through the ‘therapist continually proving himself or herself trustworthy to not exploit the client, in ‘the face ofa variety of tests and challenges, that recovery is facilitated ‘The process described in this example is one form of enactment, in that novel activity generated in the context of the therapy relationship itself becomes the basis of the development of new schemes, which then become key ingredients in novel syntheses. ‘There is a very wide range of other forms that enactment may take. These include, for example, (1) enactment of transference patterns in psychodynamic therapy, creating the opportunity to transform the relationship and alter the pat- tems through interpretation of the transference; (2) systematic desensitization in behavior therapy; (3) experiments in relational expression in gestalt therapy; (4) homework assignments in cognitive-behavioral therapy and other out-of- session experimentation (e.g., in family therapy), planned and reviewed within the therapy sessions; (5) developing new supportive relationships in group therapy; (6) enacting a new ending to an unresolved past relationship in psychodrama; and so forth. In all of these techniques, new experiences are produced, attended to, conceptualized, and ultimately conceptually and behaviorally integrated with :@ Test of the clients’ experience. Again, the diversity of forms of therapy suggest that there are a wide variety of theoretical frameworks that may guide therapists in creating novel experiences with their clients. There is also variation in the importance that particular theories of therapy and particular therapists may give to enactment of novel experionce and creation of new activity schemes (relative to the offering of new interpretations and of support in attending to existing coactivated activity schemes in novel combinatorial ways). However, every course of psychotherapy will inevitably involve novel experiences, and what is most important, from a dialectical~constructivist perspective, is the therapist's ability to collaborate with the client's efforts to organize and make sense of that experienc In sum, using lifespan developmental psychology as one’s primary frame of reference reveals great diversity in the specific ways in which therapists (1) sup- port and guide their clients’ attention, (2) generate interpretations and offer them to their clionts, and (3) contribute to clients’ enactment of novel experiences. ‘Therapists also vary in the relative importance that they place on each of these kinds of processes, and in how they conceptualize their integration. However, segardless of the extent to which the conceptual schemes and the immediate experiences reflected on are those the client brings from life outside the therapou- tic context, or are supplemented within the therapeutic context, successful psy- chotherapy fosters development through three generic processes. Each process offors powerful resources for use in clients’ own attentional challenges of creating548 Chapter 28 Rovel, more adequate organizations of immediate experience and more abstract conceptualization."? Relationships and Differences Among Theories and ‘Techniques Employed by Therapists Within clinical models of psychotherapy, techniques ideally cure disorders and theories ideally explain the disorders, as well as explain why the techniques, work. Because extant psychotherapy techniques are so varied, and theoretical Janguages and assumptions so different, so incompatible and so difficult to inte- gzate, the therapist primarily operating within a clinical frame of reference (as woll as the student attempting to learn to be a therapist) faces extremely difficult challenges. These are challenges relating to choosing from among, or integrating, theoretical perspectives and choosing among, or integrating, techniques. If it is presumed to be the technique or the theory in which the key to cure or therapeu- tic success resides, how terrifying it is to be so unsure which theary or technique is correct, and how unsatisfying itis to be “eclectic” and to feel that one is trying all sorts of interventions because of one’s own and one’s profession's degree of uncertainty regarding the true explanation of a disorder. ‘Tho developmental model presented in the preceding offers a powerful alter- native in several respects. First, in conceptualizing the goal of psychotherapy as | developmental reorganization, and in conceptualizing the locus of the reorgani- | zation processes as in the client's activity and experience as supported by tho therapeutic relationship, it recasts, and admittedly deemphasizes, the role of pre- cisely what the therapist thinks and does.” What is crucial is that the therapist _— “Greenberg and Pascual-Leone (1995) contrast the dislectcal-constructivist view of change fa ther- <3, with altemate views that emphasize “modifying cognition... intellectual insight, catharsis," ‘and “going with ones feelings" in the following way: Rather change comes about through the construction of new persoaal meaning (2. affe= tive and cognitive), which is based intielly on the eymbolization in awareness of truly ‘novel dywamic syntheses occurring in the internal field of activation, In this process, the ‘construction of new meaning is greatly facilitated by the vivid evocation in therapy of ‘emotionally Isden experience in order to bring emotional experience into contact with rllective processes. Dialectical syntheses of emotion and reflection aze the key to there- eutic change, es opposed to catharsis or reasoning alone. ‘As we have said, novel experience emerges by & process ia which aspects of different (and sometimes even opposing) schemes are synthesized into new, higher level schemes. ‘These new schemes incorporate compatible cogcivated features (not just the Corarson fe tures) of original schemes into nev unified structures with new capabilities Its therefore ‘important tat the felt experience be activated in therapy so tht clients can use it in ne ‘constructions. Purely eoaceptual or rational constructions wil nt produce enduring thes ‘peutic change because they do not involve a synthesis of emotional experioace with other laments... opporing texdeacies need to be simultaneously evoked and attended to with increased attentional effort to create a now synthesis, This ability to attend and synthesize 4s greatly faciliteted by the safety of an empathic and respectful therapeutic environment (Greenberg, Rice & Eliot, 1988). (Greenberg & Pascual-Leone, 1995, pp. 182-183) ‘Again, this is entirely consistent with the current stato of empisical research on psychotherapy out- comes, which suggests tht the psychotherapy process produces belpful results but outside very lim ited conditions, no particular theories or techniques demanstate more effective results than others, (See American Psychologist, 196).