Getting our act together: Lessons on meaningful psychotherapy research from the philosophy of...

Getting Our Act Together: Lessons on MeaningfulPsychotherapy Research from the Philosophyof Science

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David Livingstone SmithLondon, United Kingdom

Psychotherapy research should concentrate on building up a scientificallyvalidated, theoretical knowledge base by means of disciplined empiricalresearch. The normal nested relationship between technology, theory, andresearch has not been the norm in the world of psychotherapy. Psycho-therapy researchers should learn from the history of science and concen-trate on building basic theory. Investigations into the causal relationsunderpinning psychotherapy is the best way that research can help us dopsychotherapy better. These investigations must conform to the canons ofinductive reasoning. Conventional use of clinical data to underwrite psy-chotherapeutic theory is vulnerable to Grünbaum’s critique. A researchproposal based on Langs’ communicative approach to psychotherapy ispresented predicting measurable unconscious responses to brief, time-limited psychotherapy. © John Wiley & Sons, Inc. J Clin Psychol 55: 1495–1505, 1999.

What kind of research can help us to do better psychotherapy? The question itself impliesthe view that psychotherapy research has hitherto been remote from the concerns ofpracticing psychotherapists. I believe that this assessment is justified. Psychotherapyresearch has not helped us to understand and harness the forces of the mind in the waythat research in physics has allowed us to harness the forces of nature. Psychotherapyresearch has failed to deliver the clinical goods.

What is the problem? What is holding psychotherapy research back? I will attempt tocome to grips with these questions first by reflecting upon and clarifying fundamental

I would like to thank Dr. Edward Erwin for suggesting that I be invited to contribute to this special issue, mywife Subrena for her unfailing support during the composition of this paper, and to Dr. Robert E. Haskell andMrs. Marsha Taylor for their helpful comments on the draft.Correspondence concerning this article should be addressed to David Livingstone Smith, 8 Brenchley Gardens,London, SE23 3QS, United Kingdom; e-mail: DavidLSmith@dial.pipex.com.

JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 55(12), 1495–1505 (1999)© 1999 John Wiley & Sons, Inc. CCC 0021-9762/99/121495-11

methodological and philosophical issues surrounding psychotherapy research. From thisinvestigation, I will draw some conclusions about the minimal criteria that meaningfulpsychotherapy research needs to satisfy. I will then propose a modest research projectdesigned in accord with these criteria.

Research, Theory and Practice

I believe that many of our difficulties lie in the relationship between psychotherapy researchand psychotherapy theory. Psychotherapy research has not concentrated on building up afundamental, scientifically validated, theoretical knowledge base (hereafter referred to as‘basic theory’). Were psychotherapists in possession of a relevant body of basic theory,they would be in a position to deduce intervention technologies from it. In the absence ofthe quest for basic theory, it is difficult to envisage how research can make any principledcontribution to clinical innovation. Perhaps an analogy will help make this clear. Withouta scientifically sound theory of subatomic events, the existence of nuclear power stationswould be simply unimaginable. It was only through disciplined empirical research thatthis basic theory was and could be established. Quantum mechanics provided an extraor-dinarily powerful body of basic theory for the development of nuclear technologies. Bythe same token, psychotherapeutic technologies must be born from a scientifically soundunderstanding of how human minds work. This kind of understanding must be acquiredby means of empirical research.

It is normal in the sciences for research to constrain theory, which in turn constrainspractice. Research is designed to test theoretical conjectures: to determine if our guessesabout the world are really borne out by the evidence. Theories are provisionally accepted,rejected, or amended in light of the results of research. Technology involves the applica-tion of corroborated scientific theories to real-world problems. Theory can give birth totechnology only because of the tight logical relationship between the two.

This nested relationship between practice, theory, and research has not been the normin the world of psychotherapy. As Seeman (1965) stated of client-centered therapy:

Research has always followed theory and never led it. Innovations in practice have come fromdirect experience and not from research. This is in striking contrast to much medical research.A new drug or procedure is evolved and then tried out experimentally. If it works it is used ingeneral practice. Research in client-centered therapy has never served this discovery function(p. 1225).

A similar situation holds in psychoanalysis. Not only has there been very little inter-est in the use of research to interrogate and constrain theory, many psychoanalytic theo-ries do not appear to be expressed in a testable form (Smith, 1996a). Very little ofpsychoanalytic technique is logically entailed by, and therefore deducible from, psycho-analytic theory (Berger, 1985). There is a strange ‘logical independence’ of practice fromtheory in psychoanalysis (Keat, 1981, p. 162).

Against Naïve Pragmatism

Naïve pragmatism is the view that psychotherapy research should just concentrate onfinding out what works. In my view, this strategy is deeply misguided. I will illustratewhy with a vignette from the history of medicine.

Edward Jenner was an English country doctor who had the good fortune to makesome observations that led to the creation of the smallpox vaccine in 1796, a discoverythat eventually resulted in the elimination of a deadly disease from the face of the earth.

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As great as this contribution was, though, Jenner did not really understand what wasgoing on when he vaccinated his patients. Jenner did not and could not understand whatwas going on because he did not have a sound, researched basic theory to draw upon.True understanding of how vaccination works had to wait for fundamental developmentsin microbiology, immunology, and, eventually, in genetics, occurring generations afterJenner’s death. The expansion of basic theory enabled medical science to replace Jenner’sinevitably haphazard and uncertain approach with sophisticated and principled methodsof creating vaccines. Even if Jenner had not developed his procedure, it is almost certainthat the expansion of basic theory in medical science eventually would have resulted inthe discovery of vaccination (In fact, credit ultimately must be given to the ancient Chi-nese for developing a primitive method of vaccination. The absence of a researched bodybasic theory resulted in no progress being made in this domain for more than 1000 years!).

Apropos of a comparison with clinical medicine, Erwin (1997) opines:

How analogous is the current state of psychotherapeutic knowledge to the medical knowledgeof 100 years ago. . . .Most of the various forms of psychotherapy, as far as anyone knows, arenot more effective than credible placebos; the psychotherapeutic enterprise, as far as anyoneknows, does not generally consist of knowledge about how to wield techniques that can rou-tinely outperform a credible placebo (p. 145).

Psychotherapy researchers should learn from the history of science and concentrateon building basic theory. It is not very useful for researchers to work out what kind ofinterventions ‘work’ unless they are also prepared to investigate how they work. At best,standard outcome research may demonstrate that certain kinds of interventions seem toproduce psychotherapeutic effects some of the time. This in itself is of little value toanyone. The discovery that methodX eliminates phobic symptoms a little bit better than‘spontaneous’ remission would allow provides cold comfort for the clinician (in the absenceof investigations into the possible negative side effects of ostensibly helpful treatmentmodalities, such data becomes even more questionable). Clinicians want to help everyphobic patient that walks into their consulting room, not just help one every once and awhile. If researchers concentrated on establishing just how a treatment works on theoccasions when it does work, they would generate a deeper understanding of the pro-cesses underpinning the practice of psychotherapy.

There are many pathways to basic theory. There is, for instance, no reason whyresearchers should be confined to investigating instances of successful treatment. Research-ers should investigate any phenomenon that promises to throw light on those operationsof the human mind that are relevant to the practice of psychotherapy (see Langs, Badala-menti, & Thompson, 1996). Consider ‘spontaneous’ remission. Does anyone really knowhow spontaneous remission comes about? It would be extraordinarily useful to know justwhat is going on when a patient apparently recovers without the benefit of any formalpsychotherapeutic input.

Relevant research might not even have any direct connection to psychotherapy. Itwould be invaluable, for instance, to possess a body of scientifically validated knowledgeabout the ways in which human minds process emotionally disturbing information. Sucha science of emotional cognition (Langs, 1992) would have a great deal to offerpsychotherapists.

Discovery and Justification

The philosopher Hans Reichenbach (1938) proposed that scientific work is composed oftwo steps. The first step is the creation of a hypothesis. Reichenbach calls this the ‘con-

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text of discovery.’ There are no set rules for generating hypotheses. A scientific hypoth-esis can occur to one ‘out of the blue’ or as the result of hours or analysis of reflection.

Once an idea is generated, it needs to be tested against evidence to determine whetheror not it is true. Not all ideas are testable. Popper (1963) famously argued that falsifiabil-ity is the demarcating element here; in order for an idea to be scientifically meaningful,there must in principle be some way of demonstrating that it is false. In other words, theworld as depicted by a scientifically meaningful hypothesis must be incompatible withcertain logically possible states of affairs. For example, if I say that this journal is exactly211 pages long, this is a scientifically meaningful statement just because if the journalwere longer or shorter than 211 pages long, this would be incompatible with the journalas depicted in my hypothesis.

Reichenbach called the process of theory testing the ‘context of justification.’ Thereare exacting rules for testing a hypothesis in a way that is scientifically sound. A soundempirical test of a hypothesis must conform to the following methodological principles(Edelson, 1984).

1. The outcome is entailed by the hypothesis being tested.

2. The outcome is predicted, on the basis of the hypothesis, before being observed.

3. It is logically possible for the outcome not to have occurred.

4. The outcome is more consistent with the hypothesis being tested than with anyrival hypothesis addressing the same domain.

5. The test should be designed so as to rule out alternative explanations of the pre-dicted outcome.

6. If the predicted outcome fails to occur, the design of the test should rule outexplanations for this other than the falsity of the hypothesis being tested.

These six principles are built around the crucial role of prediction and retrodiction(the ‘prediction’ of the occurrence of as yet undiscovered past events). Scientific theoriesboth explain and predict phenomena. Unfortunately, it is all too easy to ‘explain’ phe-nomena. We need to have some means of winnowing true from false explanations. Pre-dictions made within an appropriately regimented research strategy allow us to do justthat. Are all scientific explanations testable in this way? Hempel and Oppenheim (1948)long ago demonstrated that there is an essential ‘parity’ between explanations and pre-dictions such that any scientific explanation can, in principle, be fashioned into a scien-tific prediction and vice versa.

The Problem of Epistemic Contamination

The field of psychotherapy has been a fertile source of ideas about human beings. It hasproposed numerous models of the mind, theories of psychopathology, and interventiontechnologies. However, psychotherapy has not been very concerned with scientificallytesting these against evidence (Smith, 1996a).

Psychotherapists have often followed Freud’s lead in citing ‘clinical evidence’ tounderwrite their ideas. Adolf Grünbaum (1984, 1993) has shown that recourse to psycho-analytic clinical data in order to underwrite psychoanalytic theory has done violence tothe principles of inductive reasoning. Specifically, it has fallen foul of the requirementthat the test must be designed in such a way as to rule out alternative explanations for thepredicted outcome.

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Grünbaum argues that clinical data cannot be used to validate psychoanalytic theo-ries because there is a powerful element of suggestion that is intrinsic to the psychoanal-ytic situation. He describes psychoanalytic data as ‘epistemically contaminated’ by thevery possibility of suggestion and shows that psychoanalysts have not managed to excludethe possibility that putative clinical confirmations of psychoanalytic theory are not, infact, due to the suggestive influence of the therapist. Grünbaum concludes that researchwill have to rely on experimental or epidemiological data rather than clinical data if it isto evaluate psychoanalytic claims in a rigorously scientific fashion. Although Grün-baum’s work on psychotherapy and science is entirely focused on psychoanalysis, hisconclusions apply across the board to the insight-orientated psychotherapies. His analysisis therefore of general significance for psychotherapy research.

What Kind of Knowledge Do We Need?

In my view, investigations into the causal relations underpinning psychotherapy is thebest way that research can help us do psychotherapy better. What are causal relations? Acausal relation holds between eventsa andb if, and only if,a contributes to the incidenceof b. A causal relationship holds between interventiona and symptomb if a makes adifference to the occurrence ofb. There are several orders of causal relation. The accountthat I have just given is an account of the relatively weak link of causal relevance. Causalnecessity holds whena is indispensable for the occurrence ofb. Causal sufficiency holdswhena is all that is required to bring aboutb.

Given that all psychotherapeutic interventions are to make a difference—to havesome effect on patients—it is more or less universally conceded that psychotherapy iscausal. Most psychotherapeutic claims appear to be claims of causal relevance, ratherthan necessity or sufficiency. I do not believe that most psychotherapists would be pre-pared to believe either that a particular intervention (or intervention kind) is all that isrequired to bring about a particular psychotherapeutic effect (or effect kind) or that aparticular intervention (or intervention kind) is indispensable to the occurrence of a par-ticular psychotherapeutic effect (or effect kind), however improbable these effects mayotherwise be regarded.

Psychotherapeutic methods presuppose the existence of some principled relationshipbetween cause and effect, and therefore of lawfully ordered causal relations. If this werenot the case, then any intervention arbitrarily could produce any effect. The practice ofpsychotherapy relies on the idea that specifiable kinds of intervention will produce spec-ifiable kinds of effect under specifiable conditions (however vaguely specifiable thesethings may be). The claim that there are lawful regularities that may underpin psycho-therapeutic practice does not entail that any one factor is fully determinate (sufficient).An intervention may be regarded as a single component of an intricate causal web.

Causal relations can only be established reliably by implementing the principles ofinductive reasoning listed above. This is just as true of those causal relations betweenevents taking place within our own minds as it is of causal relations between eventsoccurring in the external world. It follows that the causal structure of psychotherapylegitimately cannot be established by means of asking patients about their psychotherapy.Quite apart from the philosophical principle that causal relations are not directly ‘revealed’to consciousness, research in social psychology has demonstrated that causal attributionsconcerning one’s own behavior can be remarkably treacherous (Nisbett & Ross, 1980;Nisbett & Wilson, 1977). It follows that sound research cannot be based on introspectivereports about psychotherapeutic experiences.

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Most forms of psychotherapy are concerned with issues of meaning: the meaning ofsymptoms, actions, dreams, images, and so on. Meaning connections between events aresometimes falsely regarded as incompatible with causal connections between them. Manypsychotherapeutic approaches claim that causal inferences can be made on the basis ofthematic affinity. Even those theorists and clinicians who overtly reject the appropriate-ness of explaining mental life within the purview of a causal framework normally sur-reptitiously introduce causality into their explanations. Whenever we say thatb occurredbecause ofa, we are making a causal statement. Even such statements as ‘I drank thewater because I was thirsty’ are causal in this sense (Davidson, 1980).

Grünbaum (1984, 1988, 1990, 1996) has shown that thematic affinity is in itselfinsufficient for the establishing a causal relation, although it is, of course, not incompat-ible with a causal relation. Psychotherapeutic causal claims relying entirely on thematicaffinity claims must therefore be regarded as not having been scientifically validated. Thescientific validation of causal claims in psychotherapy must proceed independently ofany real or imagined ‘meaning connections’ between a purported cause and its purportedeffect.

Causal relations relevant to psychotherapy are of two basic kinds. Following Sterel-ney (1990), I refer to these as the computational and the ecological levels. The compu-tational level is concerned with how minds intrapsychically process information and istherefore interested in causal relations between events occurring within individual minds.Research on the computational level might, for example, consider how certain patterns ofthinking underpin psychopathological states. The ecological level concerns the relation-ship between minds and the world external to them (including other minds). Research onthe ecological level is therefore interested in causal relations between minds and thestimuli impacting on them. It might, for example, investigate the causal impact of par-ticular modes of intervention or features of the psychotherapeutic setting on patients.

A Research Proposal

I believe that the following research proposal satisfies all the criteria that I have identifiedfor scientifically sound and clinically meaningful psychotherapeutic research. It is basedon the theoretical and clinical innovations of Robert Langs, now known as the commu-nicative approach to psychotherapy (Smith, 1998, 1999). Although Robert Haskell (1987a,1987b, 1987c, 1988, 1989a, 1989b, 1990, 1991, 1999) has independently corroboratedaspects of Langs’work, I will not make use of Haskell’s particular empirical methodology.

Langs argues that patients are unconsciously highly sensitive to the way that theirtherapists manage the psychotherapeutic ‘frame’ (e.g., Langs, 1978, 1979, 1980, 1981,1992; Smith, 1991, 1996b; Holmes, 1998). The ‘frame’ consists of the therapeutic settingand ground rules: the most fundamental structural features defining the psychotherapeu-tic relationship.

Langs also argues that, whereas on a conscious level reactions to the frame arediverse and unpredictable, unconscious responses to the frame are remarkably uniform.According to Langs, unconscious responses to the frame are expressed only indirectly bymeans of spontaneous narratives. Narrative communication is storytelling.Aperson describ-ing the plot of a film, a childhood memory, or an event that occurred on the way to thesession is in the narrative mode. In contrast to this, the nonnarrative mode is abstract,theoretical, and reflective. A patient mulling over the meaning of life is in the nonnarra-tive mode. Langs is thus in agreement with those researchers who claim that there are twofundamental modes of human communication and thinking: the narrative and nonnarra-tive modes (Bruner, 1986; Bucci, 1997, Donald, 1991; Paivio, 1986).

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Communicative theory makes the following fundamental claims about patients’ nar-ratives in psychotherapy that manifestly are not concerned with the psychotherapeuticsituation: (a) patients’ narratives are normally evoked by aspects of the psychotherapeuticframe; (b) patients’ narratives normally express their unconscious analysis of the signif-icance of the triggering event or situation and represent that triggering event or situation;and (c) there is a lawful relationship between the narratives that patients produce intherapy and the triggers evoking these narratives.

According to communicative theory, patients unconsciously evaluate their therapists’management of the therapeutic frame. Unconscious disapproval of the therapist’s behavioris expressed by means of negatively toned narratives involving such themes as hurtfulness,incompetence, unreliability, dysfunctionality, and ignorance, whereas unconscious ap-proval is expressed indirectly through positively toned narratives involving such themes asnurturance, care, altruism, and insightfulness. These narratives are said to be ‘encoded’ inthat they manifestly do not refer to the psychotherapist or the psychotherapeutic frame.

Communicative theory asserts that all people who enter therapy unconsciously mea-sure the therapist’s conduct against a set of criteria (called the ‘secured frame’) and thatwhen therapists deviate from these standards, patients tend to respond with negativelytoned narratives that unconsciously portray the emotionally significant properties andimplications of the deviation (Langs, 1998). The main features of the secured frame are:(a) sessions take place in the same room; (b) sessions take place at the same time; (c)sessions last for the same number of minutes; (d) the patient decides when to terminatethe therapy; (e) the therapy is completely private; (f ) the therapy is completely confiden-tial;(g) contact between therapist and patient is confined to the consulting room; (h) thereis no physical contact between therapist and patient; (i) there is a set fee; ( j) the patientpays for all scheduled sessions; (k) the therapist is present for all scheduled sessions; (l)the therapist is neutral, striving not to give the patient explicit or implicit directives,blame, or praise; (m) the therapist is anonymous, striving to convey no personal infor-mation, opinions, and so on.

The term ‘trigger’ is used by communicative therapists to denote any frame eventgiving rise to unconscious response in the patient, typically, but not invariably expressedas an encoded narrative. According to Langs, there is a lawful causal relationship betweentriggers and the narratives that are evoked by them. This implies that knowledge of thetriggers active in any given session should enable one to predict the kind of narrativethemes that the patient will produce. Conversely, analysis of the narrative themes shouldenable one to retrodict their triggers. Communicative claims about prediction and retrod-iction make it possible to test these theses empirically. Furthermore, communicative claimscan be tested clinically without falling foul of the problem of epistemic contamination.This is possible because communicative hypotheses are sufficiently robust to be testedagainst clinical data taken from psychotherapeutic sessions conducted by therapists whodo not share communicative views or who even adhere to theoretical beliefs that areantagonistic to communicative theory. Under such circumstances, corroboration reason-ably cannot be attributed to the suggestive influence of the therapist.

There are many ways that communicative claims can be tested. I will focus on onlyone. According to communicative theory, brief time-limited therapy does violence to thesecured frame in that it is the therapist rather than the patient who either determines thetermination date for the therapy or implements a decision made by others (e.g., clinicpolicy). Communicative therapists call this ‘forced termination’ and regard it as anextremely powerful trigger for unconscious responses. Communicative theory predictsthat the trigger of impending forced termination evokes a high incidence of the followingtypes of narrative theme:

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1. Ending

2. Separation

3. Limited time

4. Limited quantity.

I will hereafter refer to these four themes as ‘termination themes.’Here are a few examples of the four types of termination theme itemized above:

1. Ending: Death, abortion, abortion, finishing a book, funerals.

2. Separation: Abandonment, emigration, bereavement, theft.

3. Limited Time: Deadlines, pressure of time, insufficient time to complete a task.

4. Limited Quantity: Food shortages, clothes that are to small, insufficient space.

Communicative theory also predicts that under forced-termination circumstances thesethemes predominantly will be toned negatively, and that the prevalence of negativelytoned narratives will hold irrespective of patients’ conscious attitudes towards brief time-limited psychotherapy.

I will now outline my proposed research project in light of the methodological andphilosophical points made in the present paper. The research consists of three phasesdesigned to test the communicative propositions mentioned in the preceding paragraphs.The purpose of the first phase is to assess scientifically the claim that forced termina-tion causally is relevant to the content of manifestly unrelated patient narratives inpsychotherapy.

The reference classR for the investigation will be verbatim protocols from the psy-chotherapeutic treatment of patients displaying narrative communication, as establishedby Bucci’s computerized measures for ‘referential activity’ (Bucci, 1995, 1997; Mer-genthaler & Bucci, 1993). The reference class must exclude protocols from psychother-apeutic treatments in which the patient is in treatment because of a presenting probleminvolving bereavement or loss. The reference class must also exclude protocols fromcommunicative psychotherapeutic treatments (in order to avoid epistemic contamination).

1. R is divided into the subgroupsa (protocols from brief time-limited treatments)andb (protocols from open-ended treatments). ‘Brief time-limited treatment’ isdefined for the purposes of this study as treatments that at the outset are deter-mined by the therapist or a third party as lasting no longer than ten sessions.‘Open-ended’ treatment is defined as treatment in which the patient rather thanthe therapist determines the termination date. The proposed research will notconsider treatments terminated after no longer than ten sessions at the patient’sbehest or treatments lasting for more than ten sessions but terminated at the behestof the therapist or a third party.

2. All episodes of narrative communication are identified in both subgroups.

3. For each session in subgroupsa andb, episodes of narrative communication arescored for the amount of time taken up with termination themes relative to theamount of time taken up with other narrative themes.

These ratios are averaged within each sub-group.Communicative theory predicts that the mean ratio fora will be significantly smaller

than that forb. Communicative theory further claims that patients unconsciously disap-prove of brief time-limited treatment, irrespective of their conscious evaluation of it. Thisunconscious disapproval is said to be expressed in the negative tone of termination-

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related themes. Assuming that the initial phase of the research eventuated in a positiveoutcome, the second claim can be tested as follows.

1. The reference class for the investigation consists of narrative communicationsexpressing the themes ‘ending,’ ‘separation,’ ‘limited time,’ and ‘limited quantity’from subgroupsa andb.

2. Each instance of the four narrative themes as positively toned, negatively toned,or neutral.

3. Episodes of narrative communication are scored for the amount of time taken upwith negative-termination themes relative to the amount of time taken up withother positively and neutrally toned termination themes in subgroupsa andb foreach session.

Communicative theory predicts that the mean proportion of time taken up with neg-atively toned termination themes (in comparison with the proportion of time taken upwith positive- and neutral-termination themes) will be significantly greater in subgroupathan in subgroupb.

Assuming that this claim is corroborated, do we have any reason to believe thatcommunicative theory provides the best explanation of the outcome? The research pro-cedure described above would not provide any such reason. In order to corroborate dif-ferentially the communicative explanation of the outcome, we would need to use the datagenerated to test the communicative explanation against some rival explanation. A plau-sible rival explanation for the (assumed) positive outcome is that the prevalence of thefour themes is best explained by patients’ conscious attitudes to brief time-limited ther-apy rather than their unconscious attitudes. In order to test differentially the communi-cative interpretation of a positive outcome, it is necessary to establish whether the outcomeholds irrespective of patients’ conscious attitudes.

1. Takea as the new reference class.

2. Divide a into subgroupsa1 (protocols of sessions from the brief time-limitedtreatment of patients who express a conscious approval for this modality) anda2

(protocols of sessions from the brief time-limited treatment of patients who expressconscious disapproval of this modality). Conscious approval/disapproval easilycould be established by soliciting patients’ opinions at the conclusion of therapy.

Communicative therapy predicts that there will be no significant difference in themean ratio of time spent discussing positive-termination themes to time spent discussingnegative-termination themes in the two groups.

Conclusion

In the present paper, I have attempted to spell out norms for scientifically sound, clini-cally meaningful psychotherapy research by extrapolating from work in the philosophyof science, with special reference to those philosophers of science who have concernedthemselves with psychotherapy. In doing this I have reached the conclusion that psycho-therapy suffers from the failure of research to regiment theory and the consequent impos-sibility of deducing sound techniques from scientifically unvalidated theories. I haveargued that researchers need to concentrate their efforts on establishing a body of scien-tifically validated basic theory concerned with matters of relevance to psychotherapy.Finally, I have proposed a three-tiered research project designed to test communicative

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psychotherapeutic propositions which, if corroborated, would constitute a piece of basicresearch that seems to support communicative theory about the unconscious processingof emotionally significant perceptions in the psychotherapeutic situation.

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