Socrates and the Dodo Bird: Clinical Behavior Analysis and Psychotherapy Research
Gifford, Elizabeth V., The Behavior Analyst Today
Clinical behavior analysis (CBA) is characterized by inductive observation and a pragmatic focus on outcomes. This paper argues that CBA may be useful in addressing certain issues confronted by the field of psychotherapy research. These issues include the Dodo bird dilemma, where many therapies with different purported mechanisms appear to have the same results; and Gordon Paul's famous maxim, which requires sorting out the process by which different therapies affect different individuals. A behavioral analysis of experiential avoidance is presented and discussed as one example of a behavior analytic approach to therapy process.
One of the strengths of Clinical Behavior Analysis (CBA) is its humble posture toward its subject matter. As Skinner wrote, "the subjects [are] always right. They always behave as they ought" (Skinner, 1972, p. 123). The truism that in order to hear one must first be willing to listen applies to this position. In order to listen carefully to what our subjects have to tell us, to be as receptive as possible to the events of interest, clinical behavior analysts consciously attempt a posture of ignorance. The inductive tradition underlying CBA requires that we stop talking/theorizing, and force ourselves to be quiet and pay attention. This Socratic respect for ignorance is an important part of what we do and what we have to offer to the field as a whole: careful, honest observation.
A second and related strength of CBA is its commitment to a pragmatic standard. As behaviorists, our interest is the prediction and influence of behavior. This means that we are not only careful observers as we enter a situation, we are also careful observers of the effects of our participation (1). The methods of CBA hold us accountable in that our interventions must be linked to meaningful changes in our client's actions. And in the broader field of clinical psychology, a field historically complicated by opinion, myth and other cultural heuristics, a commitment to accountability is a significant strength.
So what might these principles look like, applied to the field of psychotherapy research? Certainly there are some interesting questions facing this field at the moment. For example, large multi-site clinical trials comparing different psychotherapies, such as the NIMH Treatment of Depression Collaborative Study (Elkin, Parloff, Hadley, & Autry, 1985) and Project MATCH (Project MATCH Research Group, 1997), appear to result in moderate effect sizes of roughly the same magnitude. So in some areas we are confronted by the "Dodo bird verdict," where in a Lewis Carroll world everyone urges on their favorite therapy while the Dodo bird happily declares that "everyone has won and all must have prizes!" (Luborsky, Singer, & Luborsky, 1975, p. 995). Thus, current challenges in psychotherapy research include the following: (a) the effects of psychotherapies are often equivalent, even psychotherapies with ostensibly very different ingredients, and (b) in these cases the critical processes involved in clinical change remain unclear.
Similar concerns prompted Gordon Paul's famous question: "what treatment, by whom, is most effective for this individual with that specific problem, and under which set of circumstances?" (Paul, 1967, p. 111). There have been a number of solutions offered to this dilemma. One solution has been to gather variables within categories and create a matrix of treatment X therapist X client X problem X setting factors. A problem with this strategy is that it quickly leads to an inordinate number of cells. For example, evaluating 10 therapists X 10 clients X 10 treatments X 10 problems X 10 settings would require a matrix of 10,000 cells (Stiles, Shapiro, & Elliot, 1986). Such solutions could keep the Dodo bird happy for the indefinite future.
In contrast, CBA encourages us to go back and ask the data where and how to begin. What are the active processes that occur in sessions? …