Psychotherapy and the placebo phenomenon

Discusses the question of what makes therapy therapeutic. Argument that efficacy is
culturally contextual; Relation of psychotherapy to the placebo phenomenon; Working
ability of psychotherapy; Details on the healing process.

Question of what it is that makes therapy therapeutic is discussed in this article. Rather
than attributing efficacy to what is invoked in the content-based theories of the
psychotherapies, it is argued that efficacy is culturally contextual. Psychotherapy is
related to the placebo phenomenon, which is seen as a prime illustration of how culture
and meaning are involved in the body's healing process, and which makes no sense with a
biomedical explanation. Both placebo and psychotherapy have the common structure of
being a cultural practice of meaning-making. Therapy, then, is efficacious by setting up
the kind of context that creates meaning which heals. Some common elements of this
`healing context' are discussed.
Introduction

Therapy is a flourishing growth industry. Stocktaking at various intervals shows that

product development has been accelerating--even if we only concern ourselves with
therapy products that claim to be anchored in science. The way therapy and therapies are
promoted in the literature and at congresses supports the analogy with trade fairs and
stock markets; theories and methods are traded at rising or falling rates of exchange, and
the market fluctuates. Post-modem rhetoric has not simply encouraged `use and throw
away', but has also legitimised the philosophy of reuse: old ideas being recirculated and
presented as brand new. Though often thus presented in punchy metaphors, these are
seldom born of, or have the virtues of, old-fashioned and laborious analysis. Such
presentations satisfy the demands of the times to express oneself briefly and in `tabloid'
mode.

There is no need to be against the generation of variety in therapy, especially if the

alternative is over-simplicity; but before we encourage all the flowers of therapy to
bloom, let us remind ourselves of poor Anton Mesmer, the great hypnotist. Mesmer's
activity was in his day stopped by the French government after an evaluation by a
scientific commission. He insisted himself on that evaluation to prove that his method
had a scientific basis. Why did the commission recommend prohibiting the practice? Not
because people doubted what they saw--that his activity could heal--but because they
were not able to verify the way in which it happened. Mesmer's claimed `animal
magnetism' could not be proved (see Eysenck, 1970). It was the dawning of modemism's
greatest project, science, which reached that conclusion. In principle science still makes
the same demands: if a method of treatment or a type of medicine is to be accepted as
scientifically-based, with the rights this allows in society, there are two criteria which
must be satisfied. First, valid results of the method must 1356-9082/97/010077-11
[copyright] 1997 European Association for Psychotherapy be documented according to
scientific rules; second, it must be possible to give a plausible theoretical explanation of
why it works.
It was on this latter point that Mesmer failed, and it is on this point that alternative
medicine has problems. This is why it is still not admitted to science's intimate inner
circle. What about psychotherapy in its various forms? Can the truth have so many faces?
What do we know about therapy? Does it work?--And what is the therapeutic element
when therapy works? Before we can answer such questions, we need to be clearer about
how to think about therapy. That is my main purpose in this paper and the level of
analysis is therefore meta-therapeutic. However, the end of this analysis leads to some
conclusions about efficacy.
Does psychotherapy work?

Let us for a moment turn with our questions to the empirical research on psychotherapy.
That finally took off after Hans Eysenck in the 1960s caused a stir with the following
claim: psychotherapy has no scientifically proven effect (Eysenck, 1952, 1969). Much
research and debate has followed since then, in fayour of or against Eysenck's
provocation (see, e.g. Andrews & Harvey, 1981; Luborsky et al., 1975; Shapiro &
Shapiro, 1982; Smith & Glass, 1977; Smith et al., 1980; and an overview in Bergin &
Garfield, 1994; and critics such as Dawes, 1994). It would be an interruption of the train
of thought of this paper to stop to consider individual studies and all the complex
methodological problems involved in such research. The debate in this field has at times
been tough and uncompromising, and has illustrated that it is not simply a question of
science, but also of politics: the need and necessity of the scientific legitimisation of
therapy. As we know, science has in our time taken over the hegemony of religion as a
general basis of legitimisation. Thus it is also understandable that scientists who are
active therapists tend to interpret available data more positively than those who are not.
An attempt at realistic summary would be as follows:

(1) psychotherapy has an effect measured in a cost-benefit perspective, even if the

individual therapies do not always have it;

(2) there is no scientific basis for claiming that certain therapeutic theories/methods
generally provide more effective treatment than others;

(3) there is little scientific basis for tracing what works, when the therapy works, back to
the chosen therapeutic theory;

(4) the factors that most regularly are associated with successful therapy, therapist
variables, and relationship variables, are more important than therapy theory variables.

Where do we go from here? Shall we wait for more and improved research--more of the
same--or do the lean, and perhaps for some disappointing, results conceal something
essential? Perhaps it is not a lack of data that is the problem, but a lack of understanding
of what it tells. We must ask which sort of research paradigm can understand the nature
of this activity. Implicit in the traditional scientific approach is that it is research design
modelled on chemotherapy which is the ideal; one is to prove that a method provides an
effect on a specific condition independent of who carries out the method, the situation in
which it is practised, and characteristics of the patient other than those which are relevant
to the condition. In other words, the ideal is the context-independent method of treatment.
The claim here, which will be supported in what follows, is that by controlling all these
factors, nothing essential remains. The essential point about psychotherapy--and then in
its broadest definition--is that the potential for treatment is contextual.
Theory and rhetoric

What about our theories on therapy? What answers do they give? What hypotheses can
be supported by conclusive data? The fact that we can say today that hypnosis is not
`animal magnetism', but little about what hypnosis's, illustrates in its way the nature of
science: to invalidate relationships rather than validate them. The truth is always the final
version. Even so, the pretensions of the copious literature on therapy are not modest in
their explanations of the nature of things. As confidence about one's own activity
increases, so proportionally does one's doubt about the explanations in the literature. It
becomes impossible to believe that therapists only do what they say they do, and that the
clinical reality is as elegantly and rationally guided by technical interventions, and other
hocus pocus, as often appears from the explanations. Is it not called rationalisation when
one in retrospect creates the illusion that one's actions were based on purposeful intention
supported by rational awareness? Or is the therapist like the magician--someone who
covers up his tracks?

A more probingiy critical attitude makes a different perspective visible. Much theoretical
material on therapy has more of the character of rhetoric and politics than of the building
of theory in the formal sense. Bateson (1979) has an appropriate term for this, `smooth
theories', theories constructed so that they become self-verifying and irrefutable. A really
important theory--psychoanalysis--clearly has such characteristics, and could be
classified as a `Gnostic theory'--in other words more in line with a system of faith. As
such it risks not being falsifiable in the Popperian sense, but it may still be effective in the
realm of therapy, and scientific in a broader sense of science, in the form of a language
which can create what Bateson calls `the pattern which connects'. If we in this way see
such therapeutic theories as languages, we also see that one language is not more true
than another--they cannot be compared on such a basis. The task of language is to make
and communicate meaning.

Considering our account of psychotherapy research--and this way `of viewing theories
about therapy--we can deduce the following thesis as a basis for further discussion:

A therapeutic theory or method's eventual effectiveness is independent of whether it is

based on empirically valid premises or not.

Implication: a therapeutic theory can be clearly empirically wrong or unverified, but still
`produce' therapeutic results. At this stage we must, however, avoid drawing hasty
conclusions, e.g. that psychotherapy does not allow itself to be handled scientifically, that
it is not important which theory one adopts, or that theories as such are not necessary at
all in therapy. I shall definitely maintain that theories are necessary, and that one can talk
about good or bad ones, but only in the sense of a language. This conclusion can be
expressed as follows:

The therapist's theory functions therapeutically primarily for the therapist.

This is more than rhetoric. It underlines the completely necessary function of having a
language that enables the therapist to maintain a meaningful activity when faced with the
suffering of the client--and to maintain a faith in this meaning. Without such language the
therapist will not be able to maintain herself in an inner dialogue--and therefore nor will
she be able to put into effect the outer dialogue. Without such a language it will not be
possible to create what is part of the underlying ground in every therapeutic relationship
that does not collapse: hope.
Street comers and paradigms

Recognising the danger of exaggerating the use of metaphors, let me use a brief story to
illustrate an important point in the following reasoning. It is about the drunk who is
crawling around on a street comer and in reply to a question from a passing policeman
says that he is looking for his key. However, further questioning reveals that the key was
lost on a completely different comer. As for the decisive reason why he is searching just
where he is, he offers the explanation that the light is much better there.

It is a similar case in science. The established theories, paradigms and traditions of

understanding within a field represent the street comer with the best light. Therefore it is
there we prefer to look. However, the history of science can tell us that it is often during
chance wanderings outside science's spotlight that the keys are found which open doors
to new understandings.

Let us, for example, take a trip into the realm oft he esoteric (e.g. Romanucci-Ross, 1983)
which means what is hidden, secret--only for the initiated. What sort of activity is it that
takes place within the field inaccurately classified as `alternative medicine'? What do
healers do, the wise women (and some men), those who lay on hands and other
magicians? What was shamanism and what is it even now for large numbers of the
world's population? How do those who heal and cure in other cultures do so--not just the
illiterate, but also the traditions within the great non-western cultures?

Here there is no opportunity for a full `travel account' of any journey of exploration, only
a reflection on some experiences. The first challenge, as on most journeys, is to our own
arrogance in the face of the unknown. Personally I am `rational' (in the western sense) by
personality and upbringing, and even if we wander in the murky backstreets, it is still
important to know where there is most light. However, does the fact that we stick to
rationalism's street comer mean that we with accompanying arrogance have to reject
people's reports of healing and curing simply as nonsense, and stamp thousands of years
of medicine people's traditions as humbug and quackery?

If we stick to our working theory, the distinction between the theory and the therapeutic
effect, this is not a necessary implication. Even if we reject the theories as hopeless, this
does not mean that we must reject any possible effects. What is it then that creates
efficacy? If we are to begin to understand the diversity of types of healing, we must first
understand the culture they appear in. We can put it this way: that this treatment must be
seen as a text within the context of the culture. Forms of treatment are part of the
meaning-systems of a culture. To see this we must bring ourselves to an outsider position.
In non-literate cultures such meaning-systems are often general and comprehensive
images of the world. In highly developed cultures the differentiation and fragmentation
will be far greater. The point is still the same: meaning-systems about illness, healing and
treatment must, as with other meaningsystems, be seen as cultural evolution, as products
of man's struggle to master the various domains of existence. Cultural legitimisation, and
healers in legitimised roles, are the decisive reason for the concrete healer as a figure.
When an individual is suffering, and a certain treatment is initiated, it is the individual
adaptation which punctuates this cultural adaptation. The potential effect probably has
this interplay between culture and individuality as a precondition. If one is to understand
the effect, one must first understand the meaning, and if one is to understand the meaning
one must understand the culture.
Placebo

When confronted with such esoteric forms of healing, the biomedical scientist most
typically refers to `placebo' as an explanation. Labelling, however, is no explanation, and
is in this case more like explaining away since the placebo phenomenon is poorly
understood and dimly lit, at least at the biomedical `street comer'. In his posthumous
book Gregory Bateson says in passing that a science about man that does not even
understand the placebo phenomenon is on the wrong track (Bateson & Bateson, 1987).
He said no more about it. This utterance is, however, in line with my own intuition that
the placebo phenomenon itself is a track to a better street corner, to search for keys which
can open the door to insight into the nature of psychotherapy. Let us look into the
literature on the placebo phenomenon.

The word `placebo' means `to please' and had various meanings before it appeared in
medical literature from the 1940s as a definition of medicines as inert without direct
effect, and to explain that such medicines sometimes were felt to have an effect (Frank,
1973; Shapiro, 1971). It is striking that the placebo phenomenon is often mentioned in a
belittling or insulting manner and attributed to the curious and marginal. It is also
remarkable that only recently has the phenomenon been taken seriously in research, i.e.
not just as a source of error to control, but also as something worth researching as a
dependent variable.

When we compare the research that does at least exist, it does not reveal a picture of the
curious and marginal, but convincing results with dramatic implications for medicine's
most well-lit street corner: the biomedical paradigm. Stated briefly, empirical studies
show that not only with medicines, but also with all medicinal treatment, there is a
potential for placebo-not just as an effect, but also as a side-effect. We are talking about
real (not just imagined) effects for which the potential is greatest in conditions affected
by cortical processes. Effects of placebos are not related to special personal variables, in
other words it is a general human phenomenon, but can vary greatly in relation to
therapist and contextual variables. The variation in the strength of the placebo effect can
therefore be considerable. If we nevertheless attempt to suggest a figure by setting the
effect of any type of medicine at 100%, we can assume that placebo on average produces
an effect corresponding to 30-40%, even though the variation within individuals can go
from zero to 80%. It is also remarkable that the relationship between a medicine's
chemical potential and its placebo potential is reasonably constant. Thus morphine
placebo will provide greater pain relief than aspirin placebo (see Evans, 1974, 1981,
1985).
Placebo as a paradigmatic anomaly

How are we to understand this phenomenon? The answer shows itself to be a question of
which street corners are lit. In medicine, where there is most light, one can still find the
phenomenon described as `puzzling', but also at times presentation of research
`breakthroughs' which claim to have solved the puzzle. One example is the endorphin
hypothesis, predicated upon the background of studies that have shown endorphin effect
in pain placebo (Lipman et al., 1990); but this is explaining away, since endorphin
concerns effect variables, not cause variables. Detailed theoretical discussions have also
taken place concerning definition and proper operationalisation so that it becomes
possible to conduct research into the phenomenon (e.g. Critelli & Neumann, 1984;
Grunbaum, 1986; Kirsch, 1986).

If, however, one makes the simple reflection that when something is `puzzling' or
`deviant' this is always in relation to what is constructed as not puzzling or normal, one
realises that the placebo phenomenon is not a specific phenomenon, but appears to be so
because it represents a paradigmatic anomaly--something that according to the paradigm
should not exist, and when it does exist it threatens the very paradigm because it cannot
be explained within this. Perhaps this is the reason for its unjust treatment. Within a
paradigm that is not based on the Cartesian dualism between body and mind, there would
not be any placebo phenomenon to explain! For on any holistic integrated-body-mind
paradigm the placebo phenomenon does not stand out as requiring special or exceptional
explanation. We can therefore talk about a paradigm-constructed phenomenon. As we
have suggested it is often the anomalous that is the key to new understanding. Let us
therefore pursue the trail of the placebo in our discussion of psychotherapy.

The logical conclusion is of course that when the documented effect cannot be traced
back to the biochemical communication of a substance with the receiving body, it must
be produced by way of psychological mechanisms. Placebo effects can therefore be
classed as psychotherapeutic. As comfort and encouragement for psychotherapists,
placebo research implies convincing empirical support for the effect of psychotherapy! Is
psychotherapy therefore only placebo? Apart from the fact that the negative implication
of this `just only' is false and misleading, let us be satisfied with the conclusion that they
belong to the same class: therapeutic effects created through what we call the mental
domain. However, it is still such that the relevant empirical research is struggling with its
method design: how can one in the study of psychotherapy test for placebo phenomena?
This is where the baby disappears with the bathwater.
The mental
The trail of the placebo phenomenon leads necessarily to the old but still difficult
question of the relationship between body and mind, between spirit and matter--central to
western discourse for centuries (Priest, 1991). To understand the placebo phenomenon
and psychotherapy and their relation it is essential to explain how we comprehend and
categorise the mental domain. This can sound superfluous, and psychology as a science
should long ago have sorted out how it understands its own domain; but the history of
psychology shows us very clearly that this has been a major problem giving rise to many
epistemological errors.

Distinctions--fundamental differences--lie at the root of all knowledge. Distinctions are

decisive for what it is possible to understand. Gregory Bateson's ability to make
clarifying distinctions, as in his concept `mind', can help us a step further. Bateson says
that mind is a function of all life. He emphasises that we are balancing on a knife-edge,
and takes pains to avoid falling down on the reductionist side where it is simply matter, or
on the mentalistic side where the mental is ontologised as something substantial. `Mind is
nothing', says Bateson (1979)--and the essential here is no thing. The mental deals with
the world of substance, but is not in itself a substance. Therefore we cannot use terms
about the mental which refer to substance, e.g. `mental forces' or `psychic energy'. They
risk being epistemological anachronisms, at any rate unless they are used with a full
recognition of their metaphorical character. In the same way as we can say that matter is
characterised by energy, we can say that the mental is characterised by information and
meaning. Relationships between substances can give rise to information, but it is then the
relationship that is the information--and that is no thing, but differences between things.
To be sure, all our thinking about the real is doomed to be metaphorical, so `information'
is on the same footing as `mental force' or `psychic energy', but since the latter imply
thinking within the framework of matter and substance they are very likely to mislead us
into taking them for something more than simply metaphors. Information will often
require accompanying energy, but it is not the energy that is the information.
Correspondingly, information can release energy in living organisms, but this is energy
that is already present in the organism--and not transferred by the information or in the
information. Information or meaning is not a characteristic of the things, but our way of
understanding the things. If something has value as information, it must represent a
difference (relation), and a difference experienced by someone.
Pleroma and creatura

Bateson borrows the terms pleroma and creatura from Carl Gustav Jung. Pleroma refers
to the spatially extended matter, the physical universe in which particles and energy are
the basic elements. Creatura refers to the mental, the meaning system created by human
beings in which information is the `fundamental particle'. These are not two separate
worlds, but have a clear relationship with each other:

Apart from creatura, nothing can be known, apart from pleroma, there is nothing there to
be known.
(Bateson, 1987, p. 200)

All biological life can be informed by its surroundings and therefore can be said to have
mentality, but of course always a mentality that is in accordance with the biological
organisation. In this way the mental is always a characteristic of the biological,
inseparably linked to the way in which the biological system relates itself to the world. In
the same way as evolution has produced life in innumerable forms of hierarchies, it has
also similarly produced forms of mentality. Since evolution must also be seen as an
adaptive process, we can also see the mental as an adaptively developed characteristic.
Meaning

The level of mentality that the human organism can exhibit is a way in which our biology
expresses its adaptive capacity. If we maintain this point of departure, we can go on to
claim the ability to organise and create systems of information as a characteristic feature
of our mentality. It is this we experience as meaning. Meaning is to create relationships--
the pattern of relationships that binds together our interaction with the world. The
meaning of meaning is adaptation.

The individual's search for meaning (or adaptation) at a given point in time can, however,
never be understood as pure subjectivity. If we study meaning as subjectivity, we are
studying simultaneously inter-subjectivity--and culture. Culture is a meaning context of
which one is never on the outside. We cannot climb out of our own language. If we are
studying the mental, we are thus always also studying the culture, or the way in which
culture is punctuated by the individual. The mind is social. If we are to understand a
given example of the mental, we cannot do this by reducing the content to its biological
preconditions, but only by relating it to culture. Individual mentality thus becomes a text
within the context of culturally possible texts.
Placebo as creatura

Back to placebo. To understand the phenomenon, the most important aspect is not what
happens in the body (although that is interesting enough), because the bodily reactions
are not the cause but the effect. The essential is how the culture expresses itself through
the body. The placebo phenomenon is thus an example of Creatura's healing potential. Let
us again use the pill as an example. When taking a pill, the input is both the pill as
chemistry (pleroma) and the pill as information (creatura). As chemistry the pill is
digested through a metabolic process--biochemical communication. As a symbol the pill
is taken perceptually and is `digested' as a mental process. The pill as a symbol is not in
an inner way related to the pill's materiality, but to its meaning as creatura--in the same
way as it is not the quality of the material in a flag that creates the feeling of national
pride. In the same way that the energy that the feeling of national pride demands is not in
the flag, neither is the energy that produces the placebo effect in the pill itself. It is there
already as potential in the body, released by something the body finds meaning in. The
individual will attribute the experienced effect to the pill as a substance, since we in
everyday life usually do not behave like structural linguists and distinguish between
things and the names of things. The pill's placebo potential thus lies in its condensed
meaning--the condensing of hope and belief in relief and healing that pills symbolise in
our culture. It is the meaning that heals. In the hands of the good doctor the pill is not just
chemistry but sacrament as well. In a similar way we can substitute for the pill the
shaman's and other healers' different remedies, arts and rituals, and it is not these
remedies as substances, but their meaning in creatura that activates the mental processes
which produce the experienced effect. However, the person will attribute the effect to the
remedies (and rituals) and experience them to have magical power; but the `power' is not
in the remedy as an object. It is already in the organism, activated by the remedy as a
symbol. It is the meaning which heals, and why doubt this when it is pretty well
documented (e.g. voodoo-deaths) that meaning can kill? (Cawte, 1983; Davis, 1986;
Eastwell, 1982).

To go back to our point of departure: what is it about therapy that is therapeutic? The
reasoning leads us to the conclusion that psychotherapy essentially must be seen in the
same way as our analysis of the placebo phenomenon. What is therapeutic about
psychotherapy is the meaning. If we return to our earlier thesis about the independence of
therapeutic effects from the validity of a therapeutic theory or method, we can thus
deduce the next step:

The therapeutic potential of a theory/method is linked to the extent to which it is able to

create the meaning that has the cultural preconditions to function adaptively.
The healing process

An important precondition must now be introduced and briefly explained. The keyword is
a term already used: adaptation. Operationally we can mean by treatment or therapy: all
measures and actions that are initiated between therapist and client with the intention of
curing suffering. The healing process is, however, something more comprehensive. It is
always an implicit part of illness and suffering. All life has its own preservation as an
innate imperative. `The wisdom of the body' was Claude Bernard's way of expressing this
as far as it applied to the bodily self-regulating mechanisms. But the. body also has
mentality--and mental processes must similarly be seen as a part of the total healing
process. This healing is thus a process not simply in the body as biology, but in the body's
bio-semantic ecology. We can therefore only understand this totality by punctuating it.
Therefore, we study illness from biological, psychological, social and cultural
viewpoints. However, we have problems in putting the whole thing together again. The
body itself has not because this knowledge is itself--implicit in it through evolution's
long, and culture's far shorter, learning process.

All treatment (and treaters) will at times be free-riders in relation to the body's self-
healing ability and accept the honour for the job that the body itself has done. The point
here is that all treatment, in the way in which we have defined it above, must be seen as
sequential involvement in this healing process. What is therapeutic lies of course in the
fact that this involvement assists and forwards the process, whether the assistance is
given to the immune system or the meaning system. The treatment is, however, never
direct, but indirect in the sense that it is this healing process that `selects' what is to be
effective or not. This corresponds to Maturana and Varela's (1987) view of autopoietic
(self-meaning-creating) systems as `structurally determined' and `informationally closed'.
The implication is that the therapist can never instruct the effect, simply create the
preconditions that can assist the healing process.
The sacrament
At this point we return to the statement: the therapist's theory functions therapeutically
primarily for the therapist. To this statement must be added that this `theory' is a very
necessary precondition to enable the therapist to create something therapeutic. Theory,
and the language of theory, make it possible for the therapist both to talk to herself about
the suffering in a meaningful way (the inner dialogue), and in turn converse with the
client to create meaning (the outer dialogue). It is the therapist's mastery that is the
client's hope. In relation to the client's world the therapist must contribute with something
that creates news--news of hope and possible healing. The therapeutic situation has in
itself a communicative redundancy as far as the therapist accepts the client as he is and
remains present. Then there could be trust and readiness for the sacrament in the religious
ceremony. The sacrament is the ritual act which includes the believer in the mercy of the
holy. To accept the sacrament is an act of trust. Through her language on suffering and
healing the therapist administers the therapeutic sacrament, and must of course believe in
her sacrament, and invite the client to have trust and faith in the mercy of healing. This is
a necessary, but not sufficient, condition to allow something therapeutic to be put into
effect.
The pact

If we continue with religious metaphors, the pact is the next necessary, but still not
sufficient, condition. In religion a pact expresses a fundamental relation between the
believer and the believed in, a relation with full involvement and communion. As
salvation is presupposed by an acceptance of the pact, so the therapeutic in therapy is
conditioned by an acceptance of the therapeutic relation, the therapeutic pact.

The pact has two elements. One is epistemological in character. Therapist and client must
share fundamental preconditions in the meaning system of which the `sacrament' is a part.
This corresponds to the situation in which the believer and the minister share the belief in
the dogmas of the faith. If we are talking about psychotherapy the dogmas belong to
science. The fundamental precondition for psychotherapy, that we have a set of terms to
describe a human being's inner life, for instance, is something we take for granted in our
culture. To take something `for granted' involves not only belief but also a primary trust
beneath the reach of challenge by questions.

The other element has to do with empathy: the client confidently offers his suffering into
the care of the other person, and the therapist accepts him without fear and conditions.
We could perhaps dare to speak of love: meeting another person unassumingly. It is,
however, a love that must not tie but set free. It does so only when nothing is demanded
in return except hope and trust in the healing. Therefore the client can give himself up to
the process with responsibility for nothing other than himself. None of this is present of
its own accord---only as preconditions. The whole thing must be staged, actualised--and
the therapist is responsible for this liturgy.
The liturgy

Our point of departure was the question of what it is that is therapeutic about therapy. The
analysis implies a shift of focus--a new street-corner so to say. What therapies say that
they are by way of their theories is just one element in the therapeutic. To answer the
question about what therapy is in the ontological sense is just as meaningless as
explaining the totemic about a totem pole. Just as it is the context and the community of
the initiated that make the sculpture a totem pole, it is the context and the clients that
make the therapy therapeutic. The views that have been put forward can be called
metatherapeutic because they apply to any form of therapy whose effects are realised
through the mental domain. A fundamental problem in psychotherapy research,
recognised here and there, particularly in Gestalt therapy, is that therapy is studied as a
separate figure---separated from the context that forms it. This is an example of Anthony
Wilden's (1972) general criticism of science--that it suffers from `ecological ignorance'.
When we talk of context we are also as a rule short-sighted in the sense that we only
focus on the relevant context, contexts as situations--the treatment room's now, and forget
that this is structured beforehand by culture. Just as a religious ceremony has to be staged
according to certain rules, so also with therapy. In ceremony the liturgy frames the
context, and the minister performs the role of a stage manager. This is the role of the
therapist as well. It is not she but the context she is able to create which has the potential
to release the healing forces in the client.

If we are to study therapy, we must therefore study therapy as a context--which necessary

conditions must be created and what is sufficient to enable us to talk about what Brody
(1980) calls `the healing context'. From such a point of view the therapist's role will be to
develop the liturgy that binds these conditions together so that the healing process is
given adaptive forms.
Postludium

Is this then all there is? Of course not, but it is enough. Now we can continue our
conversation about our liturgies, techniques and methods--about how we in good and bad
ways create the healing context, about how we do even better so that the healing power is
strengthened and released. For we, as therapists, do not have this power. This is
something that we must humbly admit--it is already present in the client. The same
applies to the power of faith. It does not come from without, it is only delivered from
there. That is why my allusions to a religious discourse are not coincidental. That was
where the whole thing started--in the temple of Asclepios: healing with words and
meaning.
References

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