is distinguished professorin the psychology department

Marvin Goldfried, PhD

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

is distinguished professorin thepsychology department

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

Articles

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

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

This is the first of what will be a series of weekly blogs drawn from our podcast of the same topic and covering the most crucial questions of psychotherapy. We think it will be useful across all clinical disciplines, for practitioners, trainees, patients, and families.

, had the brilliant intuition that the "common factors" across the various types of psychotherapy may be more important to successful outcomes than the specific techniques that distinguish them. He cleverly called this the "Dodo Bird Verdict" after Dodo's famous quote in 

, "Everyone has won, and all must have prizes."

Nine decades have passed, allowing time for hundreds of controlled studies and dozens of meta-analyses, but controversy still roils regarding the relative strength of the specific versus the nonspecific factors in promoting 

1. A good therapy relationship is necessary to good outcome—but not always sufficient; and

2. Specific techniques are most differentially helpful when treating specific symptoms or behaviors (eg, anxiety, eating, or borderline personality disorders).

by Jerome Frank, MD,  PhD, gave the best description of common factors in psychotherapy and traced them to the ancient rituals practiced by shamen and shawomen.

 develop a powerful relationship. They share the belief that the shaman has special powers to heal the patient, and both have high expectations of success. The shaman allows the patient to enter a magic circle of healing and performs magic healing rituals. As a result, the patient develops insights into the causes and cures of his problems and has a corrective emotional experience, and the symptoms disappear. The patient then reenters the everyday world, healed and renewed.

It is no coincidence that modern psychotherapy so closely resembles ancient shamanic practice. Human nature is remarkably stable—what worked 50,000 years ago still works today. Expectation of symptom relief and reversal of demoralization (plus regression to the mean via tincture of time) remain very powerful drivers of change.

But modern psychotherapy also differs markedly from shamanic practice in its secular belief system: reliance on the methods of science and the development of specific, effective, and empirically supported techniques.

Every therapist should be highly skilled in establishing and maintaining powerfully healing psychotherapeutic relationships with a wide variety of patients. Every therapist should also have a toolkit of specific psychotherapeutic techniques and the wisdom to know when to use which technique with which patient. Therapists who rely only on the relation or only on the techniques restrict their therapeutic range and shortchange their patients.

This brings up the interesting question of how the

is similar to, but also different from, all other human relationships.

The similarities are obvious and pervasive. The therapist/patient relationship is just a special case of all human relations and the principles that apply to them mostly apply to it. Therapists who are good at relating to others tend to be good at relating to patients. Therapists who are bad at relating to people tend to be bad therapists. Patients who relate well in life tend to relate well in therapy and are considered easy patients. Patients who relate poorly to others in life are the ones who most need us and most teach us, even if they are considered difficult patients.

The therapy relationship also differs markedly from most other interpersonal relationships in ways that we will detail in our next blog. (Spoiler: It is more intimate, less selfish, more mutually helpful, and more assisted by high expectations and effective techniques).

 to our first podcast covering these issues in more depth.

is distinguished professor in the psychology department

Exploring the importance of the psychotherapeutic relationship.

Marvin Goldfried, PhD

Articles

Ending the Psychotherapy Civil War

Follow Your Patient, Not A Manual

Talking About Psychotherapy: A New Blog