Discussion

Designing a research program to study psychotherapy requires important and difficult decisions. One is whether to study the treatment as it is actually delivered by clinicians in the community, regardless of the methodological problems inevitably involved, or to develop a proxy treatment that is designed to permit more rigorous methodology, but nevertheless is similar enough to the treatment of interest to provide helpful information regarding it. Dynamic psychotherapy as practiced in the community is notoriously difficult to study—poorly defined, highly variable in duration, frequency, focus, theoretical assumptions and clinical strategy, and, most important, colored by the personal style of the therapist, an admixture that might be a contaminant, or might be an important therapeutic element in the treatment. Studying the outcome of such treatment directly would be like studying the efficacy of nursery school education. It would be more sensible to start with the study of a single, consistent pure intervention—perhaps watching Sesame Street.

This collection of articles describes several relatively pure psychotherapies designed to provide proxies for research on psychotherapy. They are described precisely; they have defined duration, frequency, focus, theoretical basis, and clinical strategy. It is not possible to have an algorithm that specifies exactly how a psychotherapist should conduct every element of such a treatment, but these therapies have come as close to that goal as possible. The manuals that define each of them are the current state of the art in psychotherapy research. These researchers are well aware of the potential conflict between ecological validity, the study of a treatment as it actually occurs in the world, and methodological elegance, a study that will generate results that are scientifically valid. They each emphasize the importance of flexibility in conducting the treatment while adhering to the manual that defines it. However, there is a pa