BEHAVIOR THERAPY 14, 582--586 (1983)
On the Equivalent Effectiveness of Covert Behavioral and Psychodynamic Psychotherapy COLIN MARTINDALE
University of Maine U s i n g an innovative approach, it is s h o w n that behavioral and p s y c h o d y n a m i c m e t h o d s of p s y c h o t h e r a p y are generally equally effective with all s y n d r o m e s . This is b e c a u s e virtually all patients are imaginary and are thus best treated with variants of Franzini's m e t h o d of covert therapy. It is s h o w n that covert behavioral therapy is in general neither m o r e nor less effective than covert p s y c h o d y n a m i c therapy. A m o d e s t proposal for future work is offered.
Behavior therapists often assume that some variant of behavioral therapy is superior to any type of psychodynamic therapy in treating any given syndrome. Perhaps they have reached this conclusion because they have been so busy removing symptoms that they have had no time to think the issue through. On the other hand, psychodynamic therapists often assume just the opposite. It is not at all clear how they came to this conclusion. This note sets both groups straight: Behavior therapy and psychodynamic therapy are in fact equally effective.
Ontological Status of the Patient Therapists tend to think only of living patients who present themselves at a mental health treatment facility with a symptom of some sort. As Albee (1982) has pointed out, most living people with symptoms do not in fact appear at such facilities. This may be the case, but Albee has taken a very narrow view of the problem. As Rosenhan (1973) has demonstrated, it is not necessary to have a symptom in order to be a patient. Thus, all living people are at least potential patients. Only a tiny fraction of living people appear at mental health facilities. In focusing upon the presence of symptoms, psychologists have exhibited tunnel vision. We may clearly disregard the presence of symptoms in defining a patient. Elementary considerations remind us that living people are a tiny subset of all people. The general class of people (patients) falls into four Reprint requests should be sent to Colin Martindale, D e p a r t m e n t of Psychology, University of Maine, Orono, M E 04469. 582 0005-7894/83/0582-058651.00/0 Copyright 1983by Associationfor Advancementof Behavior Therapy All rights of reproduction in any form reserved.
categories: (1) living people, (2) dead people, (3) people not yet born, and (4) imaginary people (i.e., those not falling into the first three classes). It is simple to prove by mathematical induction that the number of imaginary people is infinite. The proof should be obvious to the reader: Imagine N imaginary people. Is it possible to imagine another one? Of course. Now, given N + 1 such people, is it possible to imagine yet another? Of course, ad infinitum. Q.E.D. Given that the number of imaginary patients is infinite, it follows that the ratio of the demonstrably finite number of living, dead, and to-beborn patients to imaginary patients is for all practical purposes zero. Thus, whether behavioral or psychodynamic therapy works better for such patients is a question of no real scientific interest. The question of interest is the type of therapy that works best for imaginary patients, since such patients constitute approximately 100% of patients. The question is in fact easy to answer.
Covert Psychotherapy Franzini (1977) has developed the procedure of covert therapy. With this method, the therapist imagines a patient, the patient's symptoms, and a treatment plan. Then, the course of treatment is covertly imagined. Using covert behavioral treatments, Franzini achieved almost 100% success rates with this method. My own use of this technique yielded much lower success rates with many syndromes. Whether Franzini is a better covert therapist or has a better imagination is an open question. I extended Franzini's covert behavioral treatment to covert psychodynamic therapy. This involved a good deal of effort. Most behavioral techniques are based upon vaguely rational considerations, whereas it is not immediately apparent that this is the case with many psychodynamic techniques. For a reasonable person, it is indeed difficult even to imagine oneself doing, saying, or thinking some of the things psychodynamic therapists are reported to do, say, and think. Furthermore, doing imaginary therapy is only slightly less boring than doing real therapy. Even worse, imaginary therapy involves many ethical problems. On the one hand, it is extremely difficult to resist the sexual advances of seductive patients. On the other hand, it is difficult to avoid the temptation to kill assaultive patients by ceasing to imagine them or by even more severe covert means. In order to avoid these problems it occurred to me that rather than conducting imaginary therapy sessions and imagining the outcomes, exactly the same results would be obtained by omitting the imaginary sessions altogether and simply imagining the results directly. A colleague in our philosophy department assured me that this is logically correct. Since I do not have a license, and the Maine State guidelines for practice of psychotherapy are completely unclear as to whether such a license is necessary in order to do psychotherapy with other than living patients, my lawyer advised me that this was also the safer procedure. (When covert therapy sessions were actually held, they were labeled as single-party marriage counseling and I called myself a
biochemist in order to avoid any legal or ethical problems.) In order to be fair, I consulted several behaviorally and psychodynamically oriented colleagues. Though they showed the philosophical naivet6 typical of psychologists, all agreed that both methods made the same amount of sense. Several suggested that I should ingest drugs such as chlorpromazine or haloperidol before undertaking either method. Since they were rather vague as to exactly why this would be of any use, this suggestion was ignored.
Conditions for Which Behavioral Therapy and Psychodynamic Therapy are Equally Successful It was imagined that 10,000 imaginary patients suffering from each of the major syndromes described in DSM-III were covertly treated, half with the behavioral treatment of choice and half with what I determined to be the most appropriate psychodynamic treatment. In no case was there a statistically significant difference in outcome. Success rates varied from 0% (e.g., general paresis) to 100% (e.g., situational depression-over car keys lost but subsequently found). Therapy with imaginary patients offers the advantage of very tight controls. For example, I imagined identical twin sons of Attilla the Hun. Both presented with the diagnosis of explosive personality disorder. One was treated with Gestalt methods (sitting his aggressive urges in a chair and chatting with them) and the other with covert-covert sensitization (pairing nausea with aggressive urges). Both were completely cured. An imaginary follow-up showed no remission even after 500 years. Special Conditions for which New Therapeutic Methods are Necessary Imaginary patients present a number of syndromes not found in living patients. Among the most interesting is the delusion that the imaginary person is in fact real. This is apparently brought about by reinforcement (i.e., large numbers of dead patients, while living, believed the imaginary person to be real.) Generally, these patients have extreme delusions of grandeur. Most patients of this class are apparently extremely covertly wealthy. They tend to be imagined as living in sumptuous palaces on mountain tops and are attended by vast numbers of servants. Purely rational treatment is almost always effective: Explanation that were they real, they would probably end up on a token economy ward in a state hospital, brings an immediate end to their delusions. Incidentally, since such patients often believe that they created the world, any attempt to deal with Oedipal conflicts or birth traumas is met with total incomprehension and is thus ineffective.
Treatment of Imaginary Dead Patients For the record, it should be noted that patients who were once living but are now dead can also be treated using covert methods. Preliminary work in cemeteries revealed complete lack of responsiveness on the part
of the physical remains of such patients. However, covert methods work quite well with imagined dead patients. In contrast to the generally excellent results obtained with imaginary patients, relapse in imagined dead patients is apparently almost instantaneous with both behavioral and psychodynamic methods. For example, I cured Edgar Allan Poe of both pedophilia and alcoholism using covert aversive techniques in a single session. However, by the time I had gotten to the library to check the relevant biographies, I found that the patient had relapsed completely. When Mr. Poe arrived for his second imaginary session, I covertly cured his alcoholism while reading a sentence in the most reliable biography stating that he was an alcoholic. Although the cure was complete, the sentence did not change. Mr. Poe suggested that imaginary-imaginary therapy be used (i.e., I should imagine the results of repeated treatments). Results were clear: After 10,000 complete cures, the sentence had still not changed. Current methods of psychotherapy apparently do not work backwards in time. Other techniques clearly must be imagined for such cases. Much more research is certainly needed on this topic.
Diagnostic Status of the Patient A large number of diagnoses are not included in the D S M - I I I . The number of such diagnoses very far outnumber the number of diagnoses in D S M - I I I . Exploratory work with imaginary patients has shown that behavioral and psychodynamic methods are equally effective with a wide variety of syndromes. Success rates vary from 0% (e.g., diabetes) to 100% (most common colds are completely cured by either method in 14 days).
Conclusions Whether considered from the standpoint of the ontological status of the patient or from the standpoint of the diagnosis of the patient, we have seen that behavioral and psychodynamic therapy are equally effective in all cases. That behavioral methods usually seem to work better with living patients with real symptoms must not blind us to the fact that such patients constitute an infinitesimal minority of the total number of patients. Virtually all patients are imaginary. By definition, imaginary patients do not exist in space or time. An infinite number of them can be treated instantaneously and an infinite number will still be left to be treated. It should be obvious to the mathematically sophisticated reader that, if the number of imaginary patients is infinite, the number of such patients having any given symptom is also infinite. This will still be true if all therapists work for all eternity. Eternity is quite a long time, and eternal therapy is a good bit of work. Clearly, the federal government should put psychotherapists on the payroll for all eternity in return for such Herculean efforts. While doing imaginary therapy with imaginary patients, therapists might read my article (Martindale, 1978) showing that psychotherapy researchers almost always use completely incorrect statistical analyses to assess
their outcome results with real patients; when the correct analyses are used, results are usually negligible, insignificant, or imaginary.
REFERENCES Albee, G. W. Preventing psychopathology and promoting human potential. American Psychologist, 1982, 37, 1043-1050. Franzini, L . R . Case report of a successful innovative procedure: Covert therapy. Behavior Therapy, 1977, 8, 272-273. Martindale, C. The therapist-as-fixed-effect fallacy in psychotherapy research. Journal of Consulting and Clinical Psychology, 1978, 46, 1526-1530. Rosenhan, D . L . On being sane in insane places. Science, 1973, 179, 365-369. RECEIVED: January 24, 1983
FINAL ACCEPTANCE:February 14, 1983