A Comment on Therapeutic Change: A Response

Abstract

It is both a pleasure and honor to have been asked to respond to Hans Strupp's article "What is Therapeutic Change?" The nature of the change process has always been of great interest to me, and I welcome the opportunity to comment on it. Moreover, I have long been an admirer of Strupp's work, and have an enormous respect for his clinical and research contributions to the field. Indeed, my contacts with him over the past several years have served to broaden my perspective on the therapeutic change process. My comments will touch briefly on the following issues: The location or context in which change occurs; cognitive shifts and the necessary conditions under which these may occur; the place of techniques in the therapeutic change process; and the relevance of understanding and altering meaning structures. Where change occurs. One of the issues that Strupp and I have discussed on numerous occasions has consisted of the context in which change occurs. In his article, Strupp begins with the assumption that individuals' early experiences lead them to develop certain patterns of thinking, feeling, and behavior that ultimately prove to be maladaptive in their adult life. In order to change such patterns, suggests Strupp, the patient needs to undergo certain corrective experiences. As someone who identifies himself as a cognitive-behavior therapist, I am in total agreement with this very basic assumption. Where I would raise a question, however, is with regard to the setting within which such experiences must occur. Strupp suggests that the primary location in which this relearning occurs is within the context of the therapeutic relationship. By contrast, behavior therapists have traditionally maintained that the therapeutic relationship serves to prepare and encourage clients to take certain behavioral risks, and that real change occurs as a function of what goes on between sessions. Although it is not at all inconsistent with a behavioral orientation to view what goes on within the therapeutic relationship as providing a sample of the client's problem (Goldfried & Davison, 1976), the emphasis typically is on what happens between, rather than within, the session itself. Whether the focus should rest on within or between sessions depends very much on the case on hand, and I believe that therapists may be limiting themselves if they make the decision beforehand as to where to place this emphasis. I have seen numerous cases where individuals have been able to make significant changes in their lives with no attention at all given to the nature of the therapeutic interaction. I have also encountered instances, on the other hand, where between-session work could not take place until what was going on within the session was dealt with. For example, I recall the case of a male client who resisted engaging in between-session homework assignments designed to overcome his unassertiveness primarily because he believed that to do so would mean that he was being controlled by me. As was his response to most of the other individuals who attempted to direct his life, he assumed a passive-aggressive stance in my attempts to encourage him to become more assertive with others. It was only after he was able to assert himself to me and express how he felt in our relationship that he was willing to go out and attempt to become more assertive with others. As a behavior therapist, I think it is reasonable to assume that the therapist will at times serve as a "stimulus" for the client's problems. To assume that there is no stimulus value for the therapist or for the therapy interaction is to assume that therapy operates in a vacuum within the client's life, when in fact it is often most salient. Some behavior therapists may be reluctant to focus on the relationship because it means that they will be dealing with the "transference." Perhaps a more useful way to look at it is that a focus on what is going on within the session-as it is actually occurring-is carrying out an "in vivo" intervention. …