Allen Frances, MD

 develop their own jargons and theories, but the stages of treatment tend to be remarkably similar regardless of orientation and duration.

The patient knows things are not going well and that help is needed. The specific presenting problems are varied and very individual, but usually include some combination of symptoms, troubling behaviors, interpersonal friction, work problems, disappointment, 

, demoralization, increased stress, and/or a loss of support. The patient often has little awareness of underlying contributing factors and no idea what to do next.

As a result of the therapy—either in sessions, with 

between sessions, or ideally both—patients become increasingly aware of the emotions, thoughts, and behaviors that have created their problems, and also their reduced competence in dealing with them. They may be misinterpreting other people's motives, not recognizing their behaviors that have a negative impact on others, avoiding things that cannot be avoided, becoming too easily frustrated and demoralized, pushing people away, or any of the hundreds of ways people get stuck in vicious cycles of self-perpetuating, self-destructive behavior.

Stage 3: Corrective Emotional Experiences

Insight alone never cured anything except ignorance but becoming intellectually aware of what is causing the problem sets the stage for trying new ways of thinking, feeling, and behaving—both inside and outside the sessions. Chain reactions of corrective emotional experiences replace the downward spiraling caused by previous vicious cycles with virtuous cycles of recovery. Some corrective emotional experiences occur naturally within the context of 

, but most must come from deliberate efforts made by the patient to think in new ways, feel suppressed emotions, try new things, and stop avoiding feared situations.

If the therapy is successful, the new and healthier ways of thinking about, feeling, and acting competently in the world are internalized and become automatic.

Schools of therapy differ markedly in their theories of change, but they are very similar in their stages of change.

Crucial contextual factors in promoting change are also similar across therapies. There must be a strong therapeutic alliance. Patients must come with—or be induced to develop—at least some motivation for change and a positive expectation that therapy can help. The most effective therapies and therapists will not get very far in the process if the patient has fixed negative expectations and a fixed unwillingness to try new thoughts, feelings, and behaviors.

The stages of therapy interact with its duration in complex ways. Going from Stage 1 to Stage 2 is usually the maximal goal for patients seen only for evaluation, but some patients seen only once are able to carry forward the insight gained and achieve Stages 3 and 4 on their own through life experience or with additional later therapy. When they work well, brief treatments of 6 to 20 sessions can encompass all 4 stages. Stalemated long-term treatments may never get beyond the first or second stage. And this model of change does not apply to supportive treatments in which stability, not change, is the goal.


The best way to understand the different therapy schools is to study what they do in practice, not what they say in theory. All therapies, however seemingly different their specific techniques, succeed by facilitating corrective emotional experiences. The paths to achieve this may vary greatly, but their destination is the same.

Tune in to the full podcast to learn more. 

, we discuss the issues covered in this blog in more depth. You can view the episode 

is professor and chair emeritus in the department of psychiatry at Duke University.

Articles

Despite their differences, all psychotherapies have these things in common—and are important to consider.

Stages of Change Common to All Psychotherapies

 and an alphabet soup of 50 different named psychotherapies (

Part of this sectarian proliferation is caused by narcissistic founders' complex; part by guild interest; part by competitive parochialism; part by institutional rigidity and inertia; and part by failure to keep up with the psychotherapy research.

The result is devastating. The different schools self-destructively engage in sniping internecine warfare, instead of joining together to form an integrated and harmonious psychotherapy.

There is absolutely no good reason for competition among therapies—none is by itself necessary or sufficient, and most are completely complementary, even synergistic. Therapists who worship a narrow technique fail to grow as therapists and do a disservice to their patients. They are like hammers always in search of a nail.

We have seen, live or on tape, many of the famous representatives of the different forms of therapy conduct sessions, sometimes with the same patient. Although therapists from the various persuasions used different terms to describe what they thought they were doing, what they actually said, and the nature of the therapeutic alliance they formed, all of them were usually remarkably similar. Experienced and skilled therapists of whatever school are a lot more alike than they are different. And they are a lot more alike than their followers and trainees, who are likely to follow their founder's beliefs more than their actual behaviors.

Psychotherapy training programs tend to be remarkably parochial, rather than ecumenical. Their theoretical disputes often have the ring of how many angels can fit on the head of a pin. Our use of religious terminology to describe the behavior of psychotherapy schools is deliberate—and not meant to be flattering.

If we focus on a level of abstraction that is somewhere between the higher order theoretical constructs of a therapy school and the specific techniques that it uses clinically, there is a sweet spot middle point where we can find the greatest similarities. This will be the subject of our next blog and podcast.

For more information on ending the therapy civil wars, go to our fifth episode of the 

is distinguished professorin thepsychology department

Stony Brook University. Find them on Twitter @AllenFrancesMD and @GoldfriedMarvin.

There is absolutely no good reason for competition among therapies—none is by itself necessary or sufficient, and most are completely complementary, even synergistic. 

Ending the Psychotherapy Civil War

My short answer is "No," you do not need to buy 

, the text revision of DSM-5 that went on sale this week. You don't need it for help in diagnosing your patients or getting paid for treating them. And, you do not need it for proper coding; just about all the codes for official disorders are exactly the same as the ones that are already provided in your DSM-5.

The main new codes in DSM-5-TR are in the section "Other Conditions That May Be a Focus of Clinical Attention." These cover self-destructive behaviors that do not meet criteria for an official diagnosis. By keeping these codes handy, you can save the inflated $156 purchase price. The new codes for suicidal behavior are: T14.91A for initial encounter; T14.91D for subsequent encounter; and Z91.51 for history of suicidal behavior. For 

, the new codes are: R45.88 for current nonsuicidal self-injury and Z91.52 for history of nonsuicidal self-injury. They also re-added “unspecified mood disorder.”

 have not produced new research findings that justify a revised edition at this time. The only purpose for publishing a DSM-5-TR is planned obsolescence, linked to financial gain: DSM-5-TR was published to sell more books and reap even greater publishing profits.

There is only one significant change in DSM-5-TR, and it is a disaster. DSM-5 had already made the awful mistake of eliminating the 

 exclusion for major depressive disorder. This makes it easy to diagnose someone as having MDD just 2 weeks after losing a loved one; the only symptoms required are sadness, loss of interest and energy, and trouble sleeping and eating. This DSM-5 decision defied common sense and has been widely and justly criticized by both clinicians and grievers.

DSM-5-TR now greatly compounds DSM-5's colossal error by adding an even bigger one of its own—turning 

 into an officialmental disorder and dignifying it with a separate code. “Prolonged” is defined as just 1 year in adults and 6 months in kids.

There can never be a uniform expiration date on normal grief, and the DSM-5-TR should not feel empowered to impose one. People grieve in their own ways, for periods of time that vary widely depending on the person, the nature of the loss, and relevant cultural practices. Mislabeling grief as mental disorder stigmatizes the grievers, exposes them to unneeded psychiatric medication, and insults the dignity of their loss.

 a psychiatric disorder was based on minimal research by just a few research teams; it has not been field tested in a wide array of practice settings to smoke out harmful unintended consequences; and, perhaps most importantly, it creates all these new problems while serving no useful purpose. If a diagnosis is needed for prolonged grievers suffering "clinically significant distress or impairment," major depressive disorder has always been available.

I strongly encourage clinicians to use their common sense and clinical judgment. Don't allow DSM-5-TR's “prolonged grief” to suddenly pathologize grief. It is completely normal to grieve beyond 1 year—the small price we pay for having loved someone deeply and a big part of what makes relationships meaningful and us human.

Psychiatric diagnosis for grievers is rarely necessary; only needed when patients meet full criteria for major depressive disorder and are experiencing clinically significant distress or impairment. When a code is needed just for reimbursement,the most accurate diagnosis is adjustment disorder.

DSM-5-TR would have been worth buying if it had corrected the many mistakes found in DSM-5. Revision of DSM-5 was a golden, but lost opportunity, to revisit the many controversial decisions made by the DSM-5 Task Force—or, at very least, to have included black box warnings indicating that they remain controversial and should be used with caution. Many of the sections on differential diagnosis would have benefitted by including “normal” as a rule out.

Instead, the authors of DSM-5-TR chose to remain remarkably and uncritically true to the many flawed DSM-5 decisions.

The error consistent in DSM-5 was the introduction of many new diagnoses and the reduction of the diagnostic thresholds for existing ones. The resulting diagnostic inflation caused by mislabeling the worried well results in an awful misallocation of scarce mental health resources as well as the overtreatment of those who do not need it and the concomitant neglect of the severely ill who desperately do.

DSM-5 went wrong because its experts were given free rein to expand their “pet” diagnoses. Experts always worry about missed patients and undertreatment, never about mislabeling “normal” or overtreatment. Suggestions for new diagnoses that worked for them in their carefully researched practice are usually a disaster when over applied in regular clinical practice.

DSM-5-TR not only failed to correct the diagnostic exuberance of DSM-5, it added an additional burst of its own. Some small improvements in DSM-5-TR do not make up for the disaster of including "Prolonged Grief."

Publishing DSM-5-TR is further proof that the APA cannot be trusted to properly supervise the DSMs. We need a diagnostic system untainted by APA's huge financial conflict of interest built into its role as publisher.

 LCSW, associate professor, Loyola University School of Social Work, has provided a nice summary of the changes in DSM-5-TR.

The opinions expressed is that of the author and do not necessarily reflect the opinions of 

is professor and chair emeritus in the department of psychiatry at Duke University. Find him on Twitter @AllenFrancesMD

What do you think? Was DSM-5-TR needed? Have you purchased a copy—do you plan on buying it? We want to know your thoughts. Write to us at 

It's been 9 years since DSM 5 was released. Does this revision advance psychiatric practice?

Is DSM-5-TR Worth Buying? 

Depending on how you look at it, manuals have either played a heroic role in the history of 

 or have been responsible for its degradation.

Without manuals, we could not have built the substantial evidence base that proves the efficacy of psychotherapy and justifies its compensation.

But manuals are also accused of many sins: (1) corrupting the art of psychotherapy in pursuit of its science; (2) cheapening the therapeutic relationship by constraining it within a rigid and artificial strait jacket; (3) distorting psychotherapy training; and (4) increasing the competition among therapies and retarding their integration.

Big Bonus Of Doing Psychotherapy—It Makes You a Better Person

 therapy are particularly bitter in their criticism of manuals—blaming them for the rapid spread of 

 and the reduced popularity of their own approach. They admit that dynamic therapy is harder to standardize and study but argue that creating an “evidence base” has been fetishized at the expense of providing what is best for patients.

We must admit to them, to ourselves, and to you that we were unwitting cogs in the machine that was responsible for the undeserved power psychotherapy manuals have gained in clinical work, training, and in decisions about what forms of treatment deserve to be covered by insurance.

During the early 1980s, we first met as members of the 

National Institute of Mental Health (NIMH)

 Psychotherapy Study Section that decided which research grants were worthy of funding. Perhaps the major deciding determinant in our deliberations was whether the treatments to be studied had been manualized. It was considered a fatal flaw in any application if the treatment lacked the standardization provided by a manual, as well as adherence checks to make sure its instructions were being followed.

It is among our proudest career accomplishments that our NIMH group funded the early controlled studies of cognitive therapy, behavior therapy, cognitive-behavior therapy, dialectic-behavior therapy, and family therapy. But we are correspondingly rueful that the need for manuals in research studies resulted in their over-valuation in clinical, educational, and reimbursement decision making.

It is noteworthy that the Becks, who pioneered CBT manuals to help in research studies, have been opposed to their use in training and clinical practice. They recognized (as do most experienced clinicians) that it is impossible to simultaneously follow the patient if you are also slavishly trying to follow the manual. The manual-driven therapist becomes distracted, unemphatic, robotic, and unintuitive in adopting an attitude of do-what-the-manual-demands.

Some research studies have found treatments that more closely follow the letter of the manual achieve better outcomes than those that drift away. But this almost surely reflects correlation, not causality. Much more likely, patients who are easy-going and have good outcomes allow therapists to stick close to the manual, while the tougher patients, with less optimistic outcomes, require therapists to be more flexible, creative, and less worshipful to the manualized instructions.

It is crucial to flexibly follow the patient; not slavishly worship the manual. People are complicated and their problems are far too individual and specifically personal to ever be comprehended within any pat set of rules. It is not harmful to read manuals as a general background to understand the principles of any given therapy, but it is soul deadening to follow a manual like an automaton.

Manuals have another, more general and unforeseen detrimental effect. They encourage competition among therapies—emphasizing their differences as well as minimizing their similarities and complementarity.

Combining techniques is the best way of treating most patients—not sticking to manuals that atomize therapies and encourage reductionism. Psychotherapy integration is perhaps the most crucial topic in our field and deserves its own blog(s). Stay tuned for much more on this in later blogs.

, we discuss the issues covered in this blog in more depth, with some lame jokes thrown into the mix. Watch us 

Depending on how you look at it, manuals have either played a heroic role in the history of psychotherapy or have been responsible for its degradation.

Follow Your Patient, Not A Manual

 ever written on how psychotherapy works. The clarifying lens of Zen philosophy focuses our attention on common factors that drive change across the different forms of psychotherapy. Its author, Yutaka Ono, MD, is a master clinician most famous for bringing cognitive-behavior therapy (CBT) to 

Ancient Zen precepts, which evolved in China more than 1500 years ago, provide an excellent guide to today's best practice of psychotherapy.

. All human encounters are special, irreplaceable, and to be treasured. And few encounters are as meaningful as those that occur in therapy—enriched by unusual intimacy; the sharing deep secrets; emotional catharses; uncovering unacceptable thoughts; and revealing embarrassing experiences. No session should ever be routine, and therapy should never be the slightest bit boring for either participant.

 Every patient contact is a once-in-a-lifetime experience with the potential to powerfully change both the patient and the therapist. This is akin to the Zen concept 

, where "ichigo" means "whole life" and "iche" means "one meeting." Progress in psychotherapy does not occur in small, slowly incremental steps. We never know when something we say will stimulate a great leap forward. So, we must always, in every session, be alert for the chance to create a magic moment.

 “Life is a series of natural and spontaneous changes. Don’t resist them—that only creates sorrow. Let things flow naturally forward in whatever way they like.”

Everything is impermanent: your thoughts, your pains, your sufferings, your body, and so on. Whatever we see in our environment was once different and will soon be different yet again. This insight creates the happy expectation that therapy can be life-changing in a positive way. It also helps to reverse hopelessness and demoralization as well as promote acceptance and resilience when confronting life's inescapable losses.

 Things are never what they seem because our perception of them is so inherently subjective, self-serving, and fallible. Searching below the surface of our own attitudes and of the external world is necessary if one is ever to see things straight on and apprehend the real meaning of life.

 There is a radical difference between the experiential approach of the Zen master and the rational approach of ancient Stoic philosopher. But they do share a common understanding, re: how best to manage painful experiences. Both accept that: natural disasters will happen; people are often thoughtless or cruel; we age, get sick, and die; hardships and losses are a constant part of life. We cannot change bad events, but we can change how we react to them by learning acceptance; detachment; meditation; and desensitization via deliberate exposure to painful experiences.

 Zen is experiential, not didactic. Enlightenment relies heavily on intuition, metaphor, and poetry. The master can point in the general direction toward wisdom, but each person must find their own personal path. One's potential strength lies only within oneself; only what is internally learned is of any importance; and only by one's own personal efforts can it be increased.

 Zen speaks in puzzling riddles. Here is a typical example: "To study Zen is to study the self. To study the self is to forget the self. To forget the self is to be awakened by all things.”

Life's quandaries often have no ready solutions—we must accept that the only certainty is uncertainty.

, (the founder of Rational Emotive Therapy) acknowledged the powerful influence of the ancient Stoic philosophers in shaping their theories and therapy techniques. Less consciously, they were simultaneously injecting Zen concepts into basic foundations of the therapy methods they created.

Zen concepts are most explicit and fundamental in Dialectic Behavior Therapy (DBT), as created by 

. Linehan’s faith in Zen practice emerged from her lived experience of severe psychiatric problems during her adolescence that resisted all psychiatric treatments but responded well to Zen. DBT is a happy melding of ancient Zen practice with modern psychological techniques.

But the really great thing about the Zen concepts we have discussed is that they apply so broadly to every clinical encounter: across professions (eg, psychiatry, psychology, general medicine, social work, nursing, occupational therapy, etc); across durations of contact (eg, single meetings that last only a few minutes versus long term therapies that continue for years); and across the 50 schools of psychotherapy.

—and also periodically reread it—to forever renew the excitement that should always inform our work.

 podcast on the importance of magic moments in psychotherapy, which you can view 

The clarifying lens of Zen philosophy focuses our attention on common factors that drive change across the different forms of psychotherapy. 

Zen and the Art of Psychotherapy

 podcast, my co-host Marvin Goldstein, PhD, quoted Sidney Blatt, PhD, as saying he felt best as a person when doing psychotherapy.

I immediately resonated with Blatt's insight, realized it also applied to me, and spent the next week trying to figure out why I felt like a better man while doing therapy than in most, if not all, of my other roles in life.

I came up with these 3 interacting ways in which doing therapy is therapeutic for the therapist.

First, and perhaps foremost, is the utter unselfishness that is required if one is to correctly function as a therapist. I'm by nature not a very selfish person, but my motives aren't always purely selfless—even with those I love most. But I can recall only a few instances during a long career when I knowingly put my personal interests above my patient's—and these all had to do with choosing family first (as when my kids were born or a family member became ill). Having been unselfish with patients helped me learn how to be unselfish with others and, in the process, made me a better person.

Second comes the special intimacy that's inherent in the therapeutic relationship. I've felt closer to some of my patients than to almost everyone else in my life. It is a special privilege to share in other people's most private experiences, thoughts, feelings, hopes, heartbreaks, griefs, disappointments, and triumphs. Doing psychotherapy brought out depths of feeling in me I did not naturally have and saved me from becoming the shallow, frivolous, and immature person that was my likely destiny.

Finally, doing therapy helps therapists because it is so gratifying to be helpful to others. Not every therapy works, but most do at least to some extent, and sometimes you get to see people make really giant leaps in their lives. It's impossible to know how much you are actually contributing, and unfair and unwise to ever take credit, but it certainly feels good to be part of your patient's feeling and doing better.

I've always felt extremely grateful to my patients for letting me see the world through their eyes and teaching me so many things about life I never could have learned any other way. But I never recognized the added bonus--they were also making me a much better person and this allowed me to feel better about myself.

For more on this topic, watch the second episode of our 

Sometimes what you do for others benefits you, too. 