[Beyond the therapeutic relationship: behavioral, biological & cognitive foundations of psychotherapy]

Canadian Psychology, Feb 2000 by Leger, Frederic J, McMullen, Linda M

Frederic Leger has tackled the very large task of presenting an integrative, eclectic theory of psychotherapy which specifies the behavioural, biological, and cognitive processes that underlie psychotherapeutic change. In doing so, he follows in the tradition of other integrationists (e.g., Beutler, 1990; Prochaska, 1979) who have strived to outline frameworks that can encompass the diversity of explanatory emphases and practices in the dozens of present-day psychological therapies. In part, Leger's goal in proposing a "higher-order theory" is to lessen the "confusion which threatens to overwhelm the field" (p. 290) and to hasten a "convergence of scientific opinion" (p. 290). However, for both substantive and stylistic reasons, it is unlikely that Leger's book will have this impact.

Leger's thesis is that, while there is general consensus that the therapeutic relationship (in particular, the attitude of the therapist as specified by humanists such as Carl Rogers) is central to progress in psychotherapy, the particular facilitative therapist behaviours that promote physiological, cognitive, and behavioural changes in clients have not been adequately specified. He proposes three universal variables or classes of facilitative behaviours: (1) face-to-face interaction, in particular, dominant eye contact, (2) intensive experiential exploration, primarily through client verbalization and self-disclosure, and (3) language, especially the asymmetrical nature of talk in psychotherapy. Leger weaves these variables together in an effort to illustrate how they work to produce change in the client. He maintains that by engaging in certain nonverbal behaviours, primarily by contacting the motorically dominant eye of the client, the therapist not only communicates to the client that he or she is a person of worth, but also may promote the client's gaining more direct access to stored information which is in need of reprocessing by the brain. Contacting the motorically dominant eye, in conjunction with other empathic listening behaviours such as sensitive vocal quality, trunk lean, minimal body movement, is also considered to facilitate maximum client verbalization, particularly disclosure about the self. This disclosure is thought to unblock neural pathways by releasing stored information. The asymmetrical nature of discourse in psychotherapy, in which the client does the bulk of the talking, further increases the possibility that new thoughts will be created, new information will be released, and previously unaccessible memories will be unblocked. All of this, Leger believes, may contribute to the growth of synaptic connections in the brain which, in turn, fuel cognitive changes in the client.

Leger supports his higher-order theory by drawing from a massive amount of literature in areas as seemingly diverse as nonverbal interaction, cognitive science, physiology, neurology, and discursive psychology, as well as from his own clinical experience. And it is the scope of his knowledge and his attempt to focus the reader's attention on the importance of the often ignored influence of therapists' nonverbal behaviours and the frequently taken-for-granted effects of maximal client self-disclosure that are the most impressive features of the book. Why, then, do I think that Leger's book will not have much impact?

First, there have been several previous attempts by other writers to propose models of eclectic psychotherapy or to develop frameworks for integrating diverse forms of psychotherapy. The specifying of common factors and the recognition that most forms of therapy share many of the same features has been a part of the literature on psychotherapy for years. Yet, despite these efforts, particular approaches to therapy (albeit in hybrid forms such as cognitive-behavioural, interpersonal- dynamic, constructivist) still exist. As psychotherapists, we are willing to recognize that we have something in common with each other, but we are not willing to forsake lightly our allegiances to particular theoretical foundations. Rather than reaching consensus on a single higher-order theory, integration has been taking place (and probably will continue to take place) through the assimilation of features from one form of therapy into another. And, to some extent, even Leger has followed this pattern by starting with humanistic therapy and emphasizing a few features from other theoretical frameworks and bodies of literature that he deems to be most important.

These practices raise the question as to whether the search for a single higher-order theory is worth pursuing. In the present-day climate of manualized, empirically supported treatments (see, for example, Dobson & Craig, 1998), there is a strong movement toward choosing a particular form of therapy for a particular problem, i.e., toward problem-based specificity, not integration. In this climate, any attempt at integrative eclecticism, at what Messer (1992) defines as proposing a "single, comprehensive, and unified therapy for all clients" (p. 132), is unlikely to be widely embraced. Even apart from the current climate, the hope that we can (or should) strive toward decreasing theoretical diversity and "the current indefinite state of the field" (p. 65) is probably illusory. Psychotherapy is a complex human interaction, shaped by a myriad of factors, and our understandings of how it works (and our decisions about its practices) will continue to be based, in large part, on human interpretations. And there will continue to be diversity in these interpretations.