Abstract
Jerome Frank Baltimore: Johns Hopkins, 1961
The back cover of the paperback edition of the 1974 revised edition of Persuasion and Healing carries the following endorsement published in a review in Psychiatric Quarterly: ‘Will take its place among the classics of psychiatric literature’.
If we take ‘classic’ as in classics of English Literature to mean ageless and always having universal appeal, then Persuasion and Healing has not endured in that sense. If, however, we take ‘classic’ as in a classic example of its kind (e.g. a classic vintage motor vehicle), then emphatically ‘Yes!!’. Persuasion and Healing is a classic example of an attempt (at that time) to deliver the best in a review and evaluation of the science and art of the healing relationship as applied to psychiatric disorder in the mid-20th century.
Subsequently, Jerome Frank, then Professor of Psychiatry at the Johns Hopkins University School of Medicine, became synonymous with attempts to distil what it might be that was the essential healing ingredient in the therapeutic relationship. Although one is tempted to focus exclusively on the psycho-therapeutic relationship, it is important to emphasise that that is precisely not what Jerome Frank has done in this book. His is a review of all forms of relationships wherein minds can be altered by one technique or another, in whatever context that relationship might occur.
It is true, however, that the motivation for the writing of his book in the first place (in 1961) must have been to determine whether there was a common ‘ingredient’ in all healing relationships which could be detected in the psychotherapeutic encounter.
In Frank's own words in his preface to the revised edition: ‘The question this book attempts to explore is not whether psychotherapy works – this goes without saying – but what are the ingredients that account for the effectiveness of its many different forms.’ [Italics added]
Jerome Frank may well have been the first to ask and systematically explore this important question, although Carl Rogers and Truax and Carkhuff must be acknowledged as early workers in this specific field.
Frank draws on a bibliography of approximately 500 references in this study.
In an indisputably competitive world, the vying to be ‘the best’ and ‘more successful than’ is not absent from the world of psychotherapeutic endeavour. In 1961, Frank opens his first chapter with a quote from Lewis Carroll's Alice's Adventures in Wonderland: ‘At last the Dodo said, “Everybody has won, and all must have prizes.”’
This quotation has been taken up by others in the psychotherapy research literature (notably by Luborsky et al. in 1975 [1]) as the question to be answered: ‘is it true that everybody has won and all must have prizes?’ Is it true that all psychotherapies, no matter what their rationale, are equally effective (or equally ineffective)? If they are all equally effective, then, Frank suspects, there must be a common ingredient which brings about the desired beneficial effects in all the varied forms of therapy.
Frank establishes that a wide variety of instances of human beings having their minds ‘altered’ in one way or another has occurred since time immemorial. These include such non-therapeutic instances as religious conversions, thought reforms and brainwashings. Equally, he draws on a range of therapeutic activities which rely in one way or another upon psychological factors, for example the placebo effect, cognitive and behavioural therapies, the therapeutic community, as well as the role of the shaman in primitive societies.
Having already quoted Frank's now well-known extract from Alice's Adventures in Wonderland, it would be appropriate to acknowledge just what telling and effective use he makes of that classic text as well as its companion, Through the Looking Glass.
He begins each chapter with an apt and incisive extract from either of these two of Lewis Carroll's works. Both critics and supporters of psychotherapy as an effective technique will derive great pleasure from his selections.
He begins chapter 7, ‘The psychotherapist and the patient’ with:
‘You're thinking about something my dear, and that makes you forget to talk. I can't tell you just now what the moral of that is, but I shall remember it in a bit’
‘Perhaps it hasn't one’, Alice ventured to remark.
‘Tut, tut child!!’ said the Duchess. ‘Everything's got a moral if only you can find it.’
‘Thinking about something’ that stops the patient talking may well be resistance, while the ‘moral’ which awaits finding is the meaning which psychotherapists have confidence is always there to be found.
Chapter 8, ‘Evocative forms of individual therapies’ again offers solace to both sides of the debate:
‘Would you tell me, please, which way I ought to go from here?’
‘That depends a good deal on where you want to get to’, said the Cat.
‘I don't much care where – so long as I get somewhere’, Alice added as an explanation.
‘Oh, you're sure to do that’, said the Cat, ‘if only you walk long enough.’
This encapsulates the bane of psychotherapy research. Critics will deplore the lack of clear objectives and the open-endedness of psychotherapy, while the practitioners will respect the inherent uncertainty that is involved in human mental processes and the uniqueness of each individual's path to discovery of what ails them. Either way, the double-blind, cross-over, well-controlled study which is the current gold standard of evidence-based medicine proponents cannot be fairly applied to this form of therapy without distorting the therapy itself beyond recognition.
If Frank chooses the above excerpt for the evocative (expressive) psychotherapies, he is no less pointed in his selection for chapter 9, ‘Directive forms of individual therapies’.
‘Where do you come from?’ said the Red Queen.
‘And where are you going? Look up, speak nicely, and don't twaddle your fingers all the time.’
Despite these apparent reservations about some therapies, his quest is the search for the common ingredient among all the competing theories.
From the non-medical healing arena, both religious and secular, Frank distils a core of techniques having the ‘ability to arouse the patient's hope, bolster his self-esteem, stir him emotionally and strengthen his ties with a supportive group’ (p. 76). Such forms of healing rely on the sufferer's assumptive world ascribing a role and certain activities to a designated healer – who may be priest or shaman. Detailed confessions may be required, as might forms of atonement as the price for reacceptance into a group.
In the chapter, ‘Religious revivalism and thought reform’, Frank introduces the notion of effectiveness of these techniques and even quotes follow-up studies. He reports that at the 1950s evangelist Billy Graham's revival meetings some 2–5% of attenders ‘make a decision for Christ’, and of these, only half remain active a year later and of these, fewer than half are permanently converted. Frank suggests that earlier great evangelists such as John Wesley may have had higher conversion rates due to the possible greater potency of the threat of God's wrath in the 18th century compared with the 20th.
Over several pages, Frank deals with thought reform almost exclusively concerning himself with Chinese communism's efforts to brain-wash American soldiers and Chinese intellectuals. He contrasts the methods and objectives of psychotherapy and thought reform techniques, but highlights the importance of the intense relationship which exists in each case.
It is the way this intense relationship is conducted in the various contexts which is of utmost importance. The interrogator and persuader will exploit the intense relationship to secure their own sociopolitical ends; the shaman and other religious healers may well have the interests of the sufferer at heart, rather than their own; the evangelist may even have God's great plan in mind; but the ethical and competent psychotherapist fosters and utilises the intense relationship to facilitate the emergence of desired transference phenomena – unique to each individual patient – which may be worked through toward a resolution of psychic pain.
In a chapter on ‘Experimental studies of persuasion’, Frank reviews many studies which show that outcomes of experimental designs can be strongly influenced by subtle alterations of the experimental variables. He concludes that patients must respond to cues from their therapists, just as experimental subjects respond to the manipulations of the experimenters. While this is almost certainly so, the myth of the ‘blank screen’ idealistically proposed by Freud has long lost its adherents.
He notes that patients have been known since the earliest psychoanalytic days to dream dreams consistent with their therapists' theoretical models, but he also gives space to what he calls ‘transmission of influence through telepathy’. He cautions scepticism in accepting some reports of studies by those whom he deems ‘eager to prove its existence’. However, he acknowledges that ‘there is at least one study of telepathic influence on dreams, that is methodologically so strict that it should convince the most sceptical’ (p. 131 referring to a study by Krippner and Ullman in 1970 [2,3]).
Nowadays, the influence of therapist upon patient (and indeed, patient upon therapist!!) is more recognised as a necessary and inescapable aspect of the therapeutic relationship. This particular aspect of the relationship is that of the transference and counter-transference, and is regarded as the prime focus of attention for interpretation and understanding. Indeed, the more recently understood role and importance of projective identification may well account for what in earlier times might well have been regarded as telepathic phenomena by many who were puzzled by the reality of this mental mechanism. Freud [4,5] described the influence of one person's unconscious on the unconscious of another in two papers, one titled The unconscious and the other The uncanny.
The common features of psychotherapy
In the concluding chapter, ‘American Psychotherapy in perspective’, Frank summarises what he considers to be the four shared features of successful psychotherapies (pp. 325–329). (That Frank's book concerns itself almost exclusively with the American experience of psychotherapy is a limitation):
A relationship exists between the patient and the help-giver in which the patient has confidence in the therapist's competence and his or her desire to be of help.
The psychotherapy takes place in a locale designated by society as a place of healing.
The psychotherapy is based on a rationale or myth which includes an explanation of illness and health, deviancy and normality.
In all forms of psychotherapy, the task or procedure is prescribed by the theory.
Frank states (p. 313), ‘The number of schools of psychotherapy exceeds the tens and continues to increase.’ He would perhaps be astounded to know that nowadays there appear to be in excess of 400 identifiable ‘kinds’ of psychotherapy [6].
In an attempt to put Frank's important contribution into some kind of perspective, it might be well to briefly describe two significant current trends in psychotherapy research.
Given that Frank's subtitle is A Comparative Study Of Psychotherapy Research, and that he himself recognised some ‘tens’ of varieties of psychotherapy, even then, in the 1960s, treating the psychotherapies as a homogenous entity was fraught with problems. Nowadays, with the explosion of psychotherapeutic modalities, to speak of ‘psychotherapy’ as if it were recognisably some readily agreed therapeutic procedure has no scientific meaning.
Since Eysenck's (in)famous declaration that psychotherapy outcomes were no better than those of spontaneous remission, there have been attempts to refine the findings which were the result of subgroups of cases ‘cancelling each other out’. Thus, where a cohort of patients improve and another cohort do badly, the net outcome appears to be a ‘null’ result. Even Eysenck's own data have been re-examined [7] and suggest that ‘psychotherapy accomplishes in about 15 sessions what spontaneous remission takes two years to do’.
In a similar attempt to refine findings, Blatt et al. [8] examined subcohorts of patients in the well-known USA National Institute of Mental Health Collaborative Study of Depression and found that self-critical patients did not do at all well with any of the shorter forms of therapy, but did do appreciably well with more intense, longer-term, psychodynamically oriented therapy. In contrast, patients whose pathology seemed more related to current disruptions of interpersonal relations did well with the briefer therapies and did not do as well as the more internally oriented, self-critical cohort with the longer therapies.
Thus, while the therapies are far from homogenous, patients themselves are even less so.
So, in contrast to Frank's quest for the common ingredient, the modern-day search for the Holy Grail of psychotherapeutic efficacy seems more to reflect the question which is the title of a very recent publication by Roth and Fonagy (1996) What Works for Whom? A Critical Review of Psychotherapy Research [9].
Here the research endeavour is for the therapy to match the patient – which is of course, as it should be. Given the large variety of psychological disorders suffered by the wide variety of personalities, it is only reasonable that what is offered to patients comes close to what they need and to what they can effectively use. Regrettably, these two may not always be the same thing.
Nevertheless, it is likely that the best clinicians have always done their best to match a given patient's needs to the therapy which is offered. It is only more recently that research questions and associated methodologies have begun to reflect this and to show that indeed, some forms of psychotherapy are effective for some patients, while other forms of psychotherapy are effective for some others. It would also be well to acknowledge that not all patients can be helped by any of the psychotherapies.
Before concluding, it is important to address some implications of the words chosen by Frank in the very title of his book. While he has indeed ranged widely outside of the clinical psychotherapeutic setting in his search for the ingredients of influence of one person over another, he has, as has been often repeated, included non-medical persuasions along with medical-model healings. It needs to be acknowledged that many psychotherapists (though not all, of course) since the time of Freud's insights have sought to remove persuasion per se from the psychotherapeutic endeavour, preferring notions concerned with the patient's self-discovery, self-understanding, self-actualisation, autonomy and mastery to those wherein the power and authority of the professional are relied upon to bring about more superficial changes.
‘Healing’ itself is a notion which belongs more properly to the field of general medicine, both primitive and advanced. While some more circumscribed forms of psychic pain may lend themselves to being healed, the majority of patients presenting for psychotherapy suffer more broadly from the results of interrupted psychological development due to deprivations, abuses, traumas and the results of intrapsychic conflicts. The objectives of modern insight-oriented psychotherapy have more to do with freeing-up developmental processes and resolution of unconscious conflicts than with healing of wounds.
Human beings spend most of their lives interacting with each other. In the process they influence one another powerfully for good or ill. This book has singled out for study one particular class of influencing procedures – the psychotherapy of adults. (p. 312)
Psychotherapy at its best is a quintessentially personal relationship between patient and therapist, conducted within ethical guidelines and according to scientific principles. Jerome Frank's Persuasion and Healing was among the earliest efforts to comprehensively review the then existing literature in an attempt to distil, as a result of scientific and scholarly inquiry, the essential ingredients of the therapeutic process.
While much of what he wrote is of enduring relevance, the field has come a long way since the 1960s; and while much more is now known, many of the questions raised by Frank remain to be answered – and many other questions have been asked.