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Judith S. Beck, PhD, is president of the Beck Institute for Cognitive Behavior Therapy (CBT) 

, a nonprofit organization that provides state-of-the-art training and CBT certification to individuals and organizations, offers online courses on a variety of CBT topics, conducts research, and serves as a leading global resource for CBT. She is also Clinical Professor of Psychology in Psychiatry at the University of Pennsylvania Perelman School of Medicine. Dr Beck has written over 100 articles and chapters as well as books, workbooks, and pamphlets for professionals and nonprofessionals, including 

Cognitive Behavior Therapy, Third Edition: Basics and Beyond

Cognitive Therapy for Challenging Problems: What to Do When the Basics Don’t Work

. She has made hundreds of presentations nationally and internationally on various applications of CBT and is the primary developer of the Beck Institute’s online CBT training courses, which have been taken by health and mental health professionals in over 130 countries. Dr Beck maintains a clinical caseload at the Beck Institute’s in-house clinic in suburban Philadelphia, helping clients who are experiencing a range of challenges.

: CBT has had its fair share of criticisms over the years, and I have heard that Aaron T. Beck, MD, frequently engaged with (and at times even collaborated with) his critics. Is it accurate to say that your father’s ideas were not initially accepted by the mental health field? Do you think there are meaningful ways in which the field of CBT has benefitted from this engagement with the critics?

 as it was initially called) was not accepted by the psychoanalytic community, though my father’s ideas were favorably viewed among some psychologists, especially behavior therapists. He had originally trained as a psychoanalyst and then recognized that the theoretical constructs of psychoanalysis needed to be validated by research if psychoanalysis was to be accepted by other scientific fields.

At the time, he fully expected that his research would support the basic psychoanalytic tenets of depression. But he found the opposite. Most psychoanalysts rejected this research and later his development of cognitive therapy. More than a decade later, he found he was unable to get his first randomized controlled trial comparing imipramine with cognitive therapy for the treatment of depression published in journals. Initially he was also criticized by some behavior therapists but praised by others who integrated cognitive techniques into treatment. Throughout the years, my father has used valid criticism to refine his theories and treatment. For example, he has added a focus on processes as key agents of change. Depending on the cognitive formulation of the problem or disorder, and the individualized conceptualization of the disorder, he has supported including techniques from other evidence-based treatments. CBT has benefitted from legitimate criticism, and treatment has become more effective because of it.

: There appears to be considerable debate regarding manualized therapy in real-world clinical practice outside of research. Manuals have an understandable role to play in research settings, but to what extent should manuals constrain clinical practice? I might add here that during my own psychiatry residency training, I was taught CBT by a wonderful psychologist who emphasized basic principles of CBT and stressed the importance of developing an individualized CBT formulation to guide treatment, and I sometimes wonder how different that experience would have been if he had relied on manuals instead.

: There are various forms of CBT and to be clear, what I am talking about is the type of CBT developed by my father in the 1960s and 1970s (and refined ever since). At the Beck Institute, we do not use manuals in treatment, and we do not usually endorse the use of manuals outside of research settings. As you mentioned, manuals have a place in clinical trials to ensure that protocol therapists are delivering the same treatment to research subjects. Without manuals, the strong evidence base for CBT would not exist. But in real world settings, patients are complex. For example: they frequently have comorbidities and differ in individual characteristics such as culture, education, developmental level, socioeconomic status, and so on. Good CBT therapists tailor treatment to each individual patient, guided by their cognitive conceptualization, the patient’s presenting problems, strengths, aspirations, and goals for treatment. The treatment plan is developed, and the therapeutic interventions are selected in collaboration with the patient.

: Should CBT in clinical practice be restricted at the outset to a certain number of sessions (say 10-20 sessions) the way it is done in research settings? Or is CBT in clinical practice intended to be more open-ended and goal-dependent? My clinical observation is that when duration of CBT is not individualized and when the number of sessions is capped beforehand (often due to insurance restrictions or administrative reasons), a substantial number of patients are forced to end therapy without having experienced meaningful improvement.

: CBT in clinical practice should not be limited to a certain number of sessions. Many patients with straightforward cases of depression or anxiety can experience significant improvement within 6 to 12 sessions. However, patients with personality disorders, medical conditions, trauma histories, environmental stressors, and other complex conditions usually need a longer course of treatment. Of course, in practice, not all patients are able to complete a longer course of therapy due to monetary or practical constraints.

It is important that therapists understand and make every effort to work within these constraints, by being transparent with patients about their progress and making therapy as efficient as possible. We tell all our patients that it is not enough to come to therapy and talk for 50 minutes a week. The way they get better is to make small changes in their thinking and behavior every day. When therapists and patients finish discussing a problem or goal, therapists ask patients what they want to remember and what they want to do in the coming week. Then therapists motivate them to complete these Action Plans (formerly termed 

) between sessions to maximize the benefits of CBT and prevent relapse without prolonging treatment. Booster sessions, appropriately spaced in the weeks and months following the conclusion of treatment, are an effective way to ensure patient progress is maintained and that patients continue to practice their skills, and cope with new challenges that arise.

: Since the initial development of CBT for depression, we have seen the development of CBTs for a multitude of indications and special populations. Where has CBT been successfully applied over the decades?

: This question has been answered by research. Hofmann and colleagues did a review of meta-analyses a few years ago.

 They found that CBT has been most successfully applied to anxiety disorders, somatoform disorders, bulimia, anger control problems, and general stress. They also noted the efficacy of CBT in the treatment of depression, substance abuse, psychotic disorders, bipolar disorder, insomnia, personality disorders, criminal behaviors, and distress related to medical conditions. While most studies focus on adults, other studies show similar results for children and older adults. In addition, research has established the efficacy of appropriately tailored CBT in a multitude of settings: schools, residential programs, inpatient units, long-term psychiatric hospitals, forensic settings, community-based settings, and primary care and specialty medical clinics, to name a few.

: CBT for psychosis (CBTp) has emerged as a standard recommended treatment for schizophrenia in clinical practice guidelines such as by the National Institute for Health and Care Excellence in the United Kingdom and the American Psychiatric Association in the United States. Despite these recommendations, the availability of and access to CBTp remains limited. What are some of the difficulties that specialized interventions such as CBTp face with regards to dissemination, and what can be done about it?

: One challenge with the dissemination of specialized treatment, perhaps especially one like CBTp, is the lack of availability of individual therapy within different treatment services. While those who are especially help-seeking or those who have the support of family or other loved ones may be able to access a private practice provider, there are many individuals who cannot. In state hospitals, on community teams, in the forensic system, in residences—this is where you see many individuals who are given serious mental health diagnoses. These services often do not have the resources to offer individual therapy. Even if they did, a portion of the individuals are not help-seeking or not interested in a treatment focused on symptoms they do not see as obvious problems.

My understanding is, that as currently practiced, CBTp is primarily conducted by licensed clinicians, the vast majority of whom are psychologists. In the community and hospital settings where most care is delivered, there are many staff from other disciplines where CBTp training is not offered (social workers, licensed counselors, recreational and art therapists, occupational therapists), not to mention nonlicensed and paraprofessional staff such as direct care and peer specialists whose scope of practice does not include CBTp.

Paul Grant, PhD, and my father developed recovery-oriented cognitive therapy (CT-R) to address these limitations.

 While it can be delivered as an individual therapy, CT-R also is a very efficient group approach. It can be the basis for the therapeutic milieu and the basis of treatment planning and team-based work. Licensed and nonlicensed professionals from all disciplines can do it. It is applicable in more settings, especially those that are low-resourced. CT-R uses the cognitive model to understand how individuals get stuck and then employs powerful interventions to engage them and collaborate with them to pursue the life of their choosing.

: The development of CT-R appears to be a productive integration of 2 seemingly quite different traditions, cognitive therapy on one hand, and the recovery movement on the other. What does the recovery model add to the traditional practice of CBT?

: The power of CBT lies in the cognitive model that helps providers understand problems (eg, depression, anxiety, aggressive behavior, hallucinations, delusions, and negative symptoms) in terms of beliefs about the self, others, and the future. CBT includes specific interventions to address maladaptive beliefs and promote adaptive beliefs; it produces continued relief from distress and enables adaptive behavior.

Arthur Evans, PhD, in his previous role as commissioner of the department of behavioral health in Philadelphia, challenged my father and Paul Grant, now the codirector of the Recovery-Oriented Cognitive Therapy Program at Beck Institute, to develop a strong CT-R program for individuals diagnosed with serious mental health conditions who had historically been denied access to evidence-based practice and often languished in institutions. These individuals frequently do not seek help, do not engage in services easily, and can be very distrustful of care providers. The literature shows that they have the poorest outcomes in terms of life expectancy and quality of life.

In CT-R, the first step is to discover the individual behind the problems. Care providers focus less on psychiatric symptoms and more on identifying the life their patient wants to be living. The cognitive model turns out to be a great tool to conceptualize someone’s best self. CBT’s strengths are applied then to the whole individual. The CT-R team at Beck Institute has discovered ways to operationalize recovery principles: connection, trust, hope, purpose, and empowerment. And an age-old observation, that there are times when even the most withdrawn individuals seem more relaxed and connected to others, led to constructing the adaptive mode. This provides the framework for the strategy and interventions of CT-R, in which resilience and empowerment are emphasized. My father is first author on a recent book, 

Recovery-Oriented Cognitive Therapy for Serious Mental Health Conditions

 which shows practitioners how to practice this adaptation. And I have described how to apply CT-R principles to individuals with acute disorders in the third edition of 

Cognitive Behavior Therapy: Basics and Beyond

: How crucial is the therapeutic relationship in the successful practice of CBT? To what extent is the therapeutic benefit of CBT a result of its specific technique vs a result of common factors such as a good therapeutic relationship?

: The therapeutic relationship is paramount in CBT. One common misconception about CBT is that it is cold, rigid, and overly intellectual, and that a strong therapeutic relationship is not required. This could not be further from the truth. Good CBT therapists practice the Rogerian counseling skills of genuineness, warmth, and empathy, and they instill hope by being realistically optimistic about the patient’s situation. This is particularly important because CBT emphasizes collaboration between the patient and the therapist, both on the overarching goals of treatment, and on the issues discussed in session and the specific interventions selected. For the collaboration to be successful, the therapist must convey an accurate understanding of the patient, and the patient must trust the therapist and feel safe. CBT therapists ask for feedback at the end of each session and during the session when they notice a shift in patients’ affect. They respond to negative feedback by praising clients for being open with them. Then they conceptualize the difficulty and collaboratively plan a strategy to correct the problem. The number one rule of the therapeutic relationship, which I tell all of my trainees and psychiatric residents I teach is, “Treat every patient at every session the way you’d like to be treated if you were a patient.”

: Cognitive therapy focuses in part on the identification of cognitive distortions and negative automatic thoughts and schemas as targets of therapeutic change. In recent decades, the role of social and structural factors (such as racial inequalities and poverty) in the development of depression and other psychiatric disorders has also been recognized. There is a common criticism that sees CBT’s emphasis on locating dysfunction internal to the psyche as a way of erasing or ignoring the contributions of social injustice to psychological distress. What are your thoughts on this issue?

: A patient’s cognitive conceptualization must take into account external factors that contributed to the development and maintenance of their disorder. These external factors include family history, socioeconomic status, education level, and racism or discrimination (either experienced or witnessed). Fortunately, there is much more literature and training available now that can help therapists understand the influence of social and economic factors on mental health and the development of disorders such as depression, substance use, and PTSD, among others. Much-needed work is being done by researchers around the world to adapt CBT to different cultures and populations, from different socioeconomic backgrounds, and in different settings. This is an important area for continued research and training.

: I encounter a variety of different attitudes with regards to the psychotherapy traditions, with different therapists having different views on how compatible and complementary these various psychotherapy traditions are, and whether clinicians should align their practice along a single orientation or multiple orientations. What are your views on how the different psychotherapy traditions relate to each other, and what is your advice to therapists with regards to the plurality of psychotherapy orientations?

: In CBT, we incorporate techniques and interventions from other psychotherapeutic modalities, including acceptance and commitment therapy, dialectical behavior therapy, and mindfulness-based approaches, but our cognitive conceptualization of the patient according to the cognitive model always informs the selection of interventions. This is different from practicing eclectically. We follow the evidence and always use the best and most current research to guide our treatment decisions and select interventions.

: Dr Beck is one of the most influential figures in psychiatry and psychology and continues to do remarkable work even at the age of 100. Can you tell us about the work he is engaged in these days? What do you see as his most important legacy?

: My father still works with his research team, formerly at the University of Pennsylvania and now at Beck Institute, on the development and dissemination of CT-R. He has developed several new theoretical models that underlie the treatment and apply broadly to various diagnoses. While I do think CT-R will be a key piece of his legacy, we should not forget that before him, there really was not a concept of evidence-based psychotherapy. It is because of his work that we now know talking therapies can be effective, and in some cases, even more effective than medication.

: What do you think the future of psychotherapy is? What would you like it to be?

: A number of years ago, a colleague asked my dad whether he expected cognitive therapy to eventually dominate the field of psychotherapy. He responded, “I hope good therapy eventually dominates the field of psychotherapy. Just good therapy.” My father has always said, and I agree, that if significant research demonstrates greater support for the theoretical framework and treatment of a different psychotherapy, then that psychotherapy should supplant CBT. So far that has not happened. To the contrary, as the years have gone by, there is more and more support for CBT conceptually and in treatment efficacy.

In terms of the future of CBT, I think we will continue to use research from other fields (such as neurobiology, evolutionary biology, and cognitive science) to refine theory and guide therapy. We will continue to seek out what treatments work best for whom under what conditions. We will have a stronger emphasis on identifying key processes to target core mediators and moderators based on testable theories.

I think CBT will continue to be adapted for more problems, diagnoses, and conditions. We will train many kinds of caregivers, teachers, front-line workers, police, and even politicians. More and more health care providers, such as occupational therapists, physical therapists, primary and specialty care providers will use CBT. Eventually, if the US adopts a single-payer medical system, I think we will see a triage system like the Improving Access to Psychological Therapies program in the UK and other countries. We will see innovative ways to deliver treatment, such as by grandmothers sitting on friendship benches in Zimbabwe or lay counselors in primary care in India. We will see a greater use of technology for self-administered and computer-assisted therapy by way of apps and computer programs and a greater use of texting and telehealth services. We will also see applications of technology to better deliver training and supervision of trainees and for monitoring and evaluating therapists.

And if research continues to confirm the efficacy of CT-R, I predict that we will see principles of CT-R incorporated into the treatment of all individuals, regardless of diagnosis, severity of condition, setting, care provider, or delivery method.

The opinions expressed in the interviews are those of the participants and do not necessarily reflect the opinions of 

is a psychiatrist in Cleveland, Ohio, and clinical assistant professor of psychiatry at Case Western Reserve University. He can be reached at 

Dr Aftab and Dr Beck have no relevant financial disclosures or conflicts of interest.

1. Hofmann SG, Asnaani A, Vonk IJ, et al. The efficacy of cognitive behavioral therapy: a review of meta-analyses. 

How can cognitive behavioral therapy be adapted to different cultures and address larger social issues?

The Past, Present, and Future of Cognitive Behavioral Therapy: Q&A with Judith S. Beck, PhD

Psychiatrists are not strangers to difficult and even potentially dangerous patients, but James L. Knoll IV, MD, has made these populations one of his specialties. With decades of experience in forensic psychiatry, Knoll takes listeners deep into the US criminal justice system, where he treats both inmates suffering from detention-related psychiatric disorders and an especially challenging group that he has dubbed 

How prisons’ strict social hierarchies can contribute to psychiatric illnesses.

The high prevalence of bipolar disorder and schizophrenia in corrections—and their potential causes.

The different challenges of treating patients in prisons vs jails.

Why inmates with psychiatric illnesses end up in the correctional system for longer than those without psychiatric illnesses.

The role of mental health courts in improving psychiatric care in the correctional system.

The challenges of treating patients who are high in psychopathy or have anti-social personality disorders.

, in which Knoll talks about how he first became interested in forensic psychiatry (at age 10). 

is professor of psychiatry and director of forensic psychiatry at SUNY Upstate Medical University in Syracuse, New York, and clinical director of Central New York Psychiatric Center in Marcy, New York. He is Emeritus Editor-in-Chief of the 

 and President-elect of the American Academy of Psychiatry and the Law (2022-23).

James L. Knoll IV, MD, shares insights from his decades in forensic psychiatry, where he has treated some of the criminal justice system’s most difficult and dangerous patients. 

Treating ‘Morally Objectionable’ Patients

For many young patients (and their parents) the back-to-school season is an anxious time. How will they navigate their new classes? Will they get along with their teachers? Will they make friends? Their active imaginations can invent a hundred scary scenarios.

But what if their brilliant imaginations could help them build resilience instead? In this Mental Health Minute, Victoria Harris, DPsych, MA, offers practical tips and techniques to help children overcome their fears through the power of their creativity.

is a Humanistic & Integrative Psychotherapist and Supervisor in private practice who specializes in using creative techniques. She has trained in child psychotherapy and play therapy and researched the use of creative techniques in psychotherapy at Dublin City University. she helped develop a well-being school programme for 3rd & 4th class in Ireland for the charity 

 uses metaphor to help children navigate anxiety and loss will be released on October 5th, 2021. Dr. Harris believes strongly in early intervention and using creativity as a tool for healing.

How do you prepare patients for the back-to-school season? 

Share comments with your colleagues by emailing 

. Comments may be shared online pending review and editing for style.

These imaginative exercises can help clinicians establish a strong therapeutic alliance with nervous youngsters. 

Looking for a Way to Beat Back-to-School Anxiety? Maybe It’s Time to Get Creative

Conversations in Critical Psychiatry is an interview series that explores critical and philosophical perspectives in psychiatry and engages with prominent commentators within and outside the profession who have made meaningful criticisms of the status quo.

, FRCPC, PhD, DPhil, is Professor and Chair of the Department of Psychiatry at the University of Cape Town (UCT), Cape Town, South Africa. Dr Stein did his undergraduate and medical training at UCT. To avoid compulsory service in the all-white South African army he left for the United States, where he completed his residency in psychiatry and a postdoctoral fellowship in psychopharmacology at Columbia University. After Mandela was democratically elected President, Dr Stein returned to South Africa where he has remained since. His training also includes a PhD in clinical neuroscience, and a DPhil in philosophy, both from Stellenbosch University. His research work has focused on anxiety and related disorders, including obsessive compulsive and related disorders, and trauma and stressor-related disorders. He chaired the DSM-5 and the ICD-11 workgroups on obsessive-compulsive and related disorders. His own research has been continuously funded since his residency, and has had significant impact, as evidenced by a Google scholar h-index>140, by the broad range of work led by his mentees, and by research awards including the Ethics in Psychopharmacology award by the International College of Neuropsychopharmacology. He has received the Lifetime Achievement Award from the World Federation of Societies of Biological Psychiatry.

Dr Stein has been interested in both psychiatry research and in philosophical writing since his residency. As a resident, he won the Karl Jaspers Award from the Association for the Advancement of Psychiatry and Philosophy in 1991 (I had the privilege of winning the same award in 2018). As part of the DSM-5 revision process he wrote an article, collaborating with a number of leading figures in philosophy and psychiatry, titled “

What is a mental/psychiatric disorder? From DSM-IV to DSM-V

” that has been cited nearly 500 times.

 In 2008, he brought together his interests in psychopharmacology and philosophy in 

 (Cambridge University Press, 2008) and this year he has further extended his work in philosophy with the publication of 

Problems of Living: Perspectives from Philosophy, Psychiatry, and Cognitive-Affective Science

 (Academic Press, 2021). This is an ambitious book, tackling questions not only about the nature of mental disorders, but also about the mind-body problem, the relationship between reason and emotion, happiness and suffering, morality and truth, and the meaning of life.

: You are the first African author I have interviewed for this series. Does being South African influence your work on philosophy and psychiatry?

: Well, it is notable that South Africans have made some really important contributions to psychiatry. The work of Joseph Wolpe, MD, developing behavior therapy comes to mind, as does Isaac Marks, MD’s contribution to anxiety disorders (others are detailed in a 

 On the other hand, critiques of psychiatry have had particular resonance here, emphasizing how social determinants and health systems are closely bound up with the history of apartheid and continue to influence mental health. From early on in my studies I was aware of both the positive contributions of psychiatry, as well as of important critiques of the field, and wondering what to make of this.

: Your specific interest in the philosophy of psychopharmacology distinguishes you from many other authors and commentators in this area. Psychopharmacology too is a field where there have been advances, but also important limitations.

: Yes, I fully agree. The introduction of antipsychotics, antidepressants, anxiolytics, and mood stabilizers in the 20th century was a complete game-changer for psychiatry. At the same time, the receptors targeted by early agents continue to by and large remain the focus of current clinical psychopharmacology. Neuroscience has become increasingly sophisticated, and yet our understanding of how psychotropics affect symptom relief remains somewhat rudimentary. We should celebrate the fact that appropriate diagnosis and pharmacotherapy of changes many individuals’ lives for the better. But we must remain aware that there is massive underdiagnosis, particularly in low- and middle-income countries, that not all patients respond to pharmacotherapy or other interventions, and that over-diagnosis and over-treatment is also an issue.

: Selective serotonin reuptake inhibitors (SSRIs) and other antidepressant medications have been the subject of a lot of controversy in recent years. There is the perpetual question: why have they performed so poorly when compared to placebos in randomized controlled trials (RCTs) and what does that say about their real-world clinical efficacy? There is increasing awareness of the prevalence and severity of antidepressant withdrawal, and other adverse effects. There is the implosion of the popular idea that antidepressants exert their effect by correcting some biochemical abnormality in individuals with depression. And there is the escalating search for more potent psychopharmacological interventions for treatment resistance. As someone who approaches psychopharmacology through a philosophical lens, how do you view these developments? Are they reflective of a deeper malaise in the field of psychopharmacology? Have we been asking the right sorts of questions about efficacy, safety, and mechanism of action? Has there been something lacking in our mainstream conceptual understanding of psychopharmacology that is being reflected in these on-going discussions?

: In my thinking about these sorts of issues in psychopharmacology, and related questions in philosophy of psychiatry, I find myself always trying to walk the line between overly hagiographic accounts and overly critical views of psychiatry. When I think of how psychotropics can impact thinking and feeling, and be so therapeutic, I am filled with awe (about the complexity of the relevant mechanisms), and with gratitude (that we are able to help individuals suffering from mental disorders). But I am also very aware of the robust criticisms of psychopharmacology’s evidence-base, of iatrogenic illness, and of how far we still have to travel in psychopharmacology. I don’t think there’s a deep and readily addressed conceptual solution in psychopharmacology research. We have long been aware, for example, that neurotransmitters cut across dimensions of behavior (the pioneering work of Herman van Praag, MD, PhD comes to mind), and that while psychopharmacological dissection may be a useful tool (one of my mentors was Donald Klein, MD!) the idea that there is going to be a specific psychotropic that is particularly effective for each disorder is way too simplistic.

I do think, though, that in clinical practice it may be helpful to think about psychopharmacology not only from a molecular perspective, but also from an evolutionary medicine perspective (Randolph Nesse, MD, is another of my mentors!). This helps explain why anxiety is so common, why there are endogenous anxiogenic and anxiolytic mechanisms (which we can then target or mimic), why medications that target adaptive defenses can be clinically useful (an antitussive can reduce symptoms even though cough is highly adaptive), and why the motto “a pill for every ill” is far from the solution. From a research perspective, while I love the current idea that clinical trials can be based on translational neuroscience approaches (eg, testing if a drug alters an important biomarker or endophenotype), successful bench-to-bedside advances remain fairly unusual in psychiatry, and I worry that we do not put commensurate attention and funding into pragmatic clinical trials. The United Kingdom’s Recovery Trial to quickly test drugs for efficacy against COVID-19 in day-to-day practice is inspiring. Should we not be doing the same sort of thing for mental disorders? (I hope Josh Gordon, MD, PhD, and Miranda Wolpert, PhD, are readers of your column!)

: I hope they are too! You have often differentiated between the 

 positions. Tell us a bit more about these, particularly as you envisage them with regards to psychiatry.

: I have used these terms in part to find a middle path that I mentioned earlier, avoiding both overly hagiographic and overly critical views of psychiatry and psychopharmacology. I have also used them to help find a way of integrating key philosophical views on science, language, and medicine. Thus, I use the term 

 to refer to positions that emphasize essential natural kinds and scientific laws, holding up, say, the periodic table as an example of how science should work, and arguing that diseases too have essential features, which we need to explain. And I use the term 

 to refer to positions that emphasize social construction and hermeneutic methods, pointing out that our concepts vary from time to time and place to place, arguing that mental disorders are socially constructed and that the experience of being ill needs to be understood. I try to put forward an 

 approach which avoids the scientism of the classical view and the skepticism of the critical view, and which sees science (including psychiatric science) as both a social activity, and as providing powerful accounts of the structures, processes, and mechanisms underlying phenomena, including disorders.

: Among the philosophers who have had a formative influence on your intellectual development, you mention the British philosopher Roy Bhaskar, PhD, and his critical realism. What are some of the fundamental ideas of critical realism and what do you think they have to offer to our philosophical understanding of science and psychiatry?

: Bhaskar taught me that science is both a social activity and provides powerful accounts of real phenomena, and I continue to find his naturalistic account particularly persuasive. In arguing that this account can be extended to the social sciences, I see critical realism as integrating philosophical positions that focus on 

), mechanisms, and facts in the social sciences, together with positions that focus on the importance of 

), narratives, and values in these fields. In my mind, this kind of integrative approach is redolent of work of the psychiatrist-philosopher Karl Jaspers, who I also see as emphasizing the importance of both explanation and understanding.

: You have also been heavily influenced by pragmatic philosophers such as John Dewey, PhD, and by the work of George Lakoff, PhD, and Mark L. Johnson, PhD. Can you say more about why you see the work of these authors as important, and what you think they have to offer to our philosophical understanding of science and psychiatry?

: Bhaskar is interested in the success of science, and he provides a 

 account of this success. Lakoff and Johnson are particularly interested in the findings of cognitive science, which views mind as embodied (in the brain) and embedded (in society). For me, their 

 helps account for many additional phenomena, including for example our metaphors of disease. Dewey’s 

 is older than the work of these modern authors, but in my mind, it prefigures it. He emphasized, for example, how knowledge is not so much based on a representation of the world, but rather is more based on engagement with the world. The classical position is a naturalist one, but by seeing physics and chemistry as the exemplars of science par excellence, it runs the risk of scientism and reductionism. I see pragmatic, critical, and embodied realism as allowing a 

 that emphasizes the complexity of the world, the usefulness of multiple explanations of such multilayered concepts as disease, and the intertwining of facts and values in medicine and psychiatry.

: Jaspers’ methodological pluralism sees 

 as distinct methods with distinct advantages and limitations such that are both essential in the realm of psychology and psychopathology. However, in such a methodological pluralism, 

 remain incommensurable, coexisting, but without a meaningful connection or bridge. When you talk about the bridging the 

 divide, do you mean the same thing as Jasperian pluralism, or do you mean something different, perhaps a sort of naturalistic account which can explain how 

: That is a great question, that I suppose I am still struggling with. I see 

 as commensurable, and I am hopeful that scientific explanations, although multiple, can be integrated. Ken Kendler, MD, who like you and me is a fan of explanatory pluralism, has put forward the notion of 

 and perhaps this sort of idea is able to form the basis of a bridge. We sometimes forget how deeply metaphoric our concepts are, and I wonder if some of the gap between 

 is based on how they use different metaphors for science and for psychiatry. My intuition is that a more comprehensive metaphor of science and psychiatry would allow a better bridge, and more successful integration. I find the schema construct or metaphor particularly useful in bridging psychodynamic and cognitive-behavioral theory and practice, and I would suggest that work on schemas may also be useful in accounting for how humans including clinicians bring together 

. Would you like to introduce the book to the readers in your own words? What are some of the major themes and conclusions of the book?

: It has been more than a decade since I wrote 

, and I have been wanting to get back to thinking about philosophy and psychiatry. I have been fortunate that a postdoctoral fellowship in philosophy and psychiatry was established in our department, and this has encouraged me to do so. I see the volume as expanding on my earlier work in a few key ways. First, whereas my earlier volume was on psychopharmacology, here I draw on a whole range of different scientific findings about the brain-mind. Second, my earlier volume spoke mainly about scientific naturalism and explanatory pluralism, but here I expand more on moral naturalism and value pluralism. Third, my earlier volume spoke mainly to the philosophy and ethics of psychopharmacology, whereas here I expand to cover the philosophy and ethics of a range of aspects of human life, including the question of the meaning of life.

There are also key continuities between the volumes. First, I continue to use the framework of classical, critical, and integrative positions to help frame philosophical and psychiatric debates. Second, I continue to be committed to scientific and moral naturalism, hoping that humans can achieve progress in both arenas through rigorous thinking-imagining, and paying attention to facts and values, and to principles and particulars. Third, I think I remain keenly aware of both the value and harms of science and psychiatry, and indeed the pros and cons of life more generally. The possibility of a middle way, of a balanced approach, is a central issue for me, and I hope the volume is useful for readers also interested in that kind of path.

Given my interest in embodied cognition, I am very aware that expressions such as “a middle way forwards” and “a balanced approach” employ metaphors. My last chapter in 

 is a brief reflection on the metaphors we use for thinking through life, the big questions and hard problems that it raises, and ultimately its meaning. I suggest that the metaphor of 

 may be a particularly useful one, and I spend some time in fleshing it out, and in advocating engagement with the world (rather than the sort of navel-gazing that some seem to advocate), and encouraging a course that avoids both unbridled optimism and relentless pessimism (of the sort that is seen in some self-help and philosophical literature). It is a bit whimsical in spirit, but I hope it appeals to at least some readers.

 to talk about brain-minds. Can you tell us more about it and what you see as the advantage of employing this metaphor?

: The mind-body problem includes the hard problem of consciousness, and key philosophical positions include physicalism, dualism, and functionalism, which relies in part on the hardware-software distinction in cognitive science. We increasingly use the hardware-software metaphor in everyday life, as well as in psychiatry. It is easy for us to talk about medications as changing our hardware, and psychotherapy as changing our software. But while brain-as-thinking-machine metaphors can be useful, they also lead to important errors: psychiatry needs to remain vigilant and avoid brainless and mindless approaches. For me, the term 

 helps emphasize how the brain-mind (a term I think we should use more often) is biological through and through, with cognitive-affective phenomena embodied in brain processes and embedded in social activity.

: Something I found really fascinating and insightful was your discussion of wetware and placebo response. You write, “the placebo response can be characterized as embodied in our particular wetware (and underpinned by a range of specific psychobiological mechanisms), and as embedded in our interactions with healers (which are powerfully meaningful for us). We might therefore propose a placebo Turing test: a computer may be considered to think and feel if it demonstrates a placebo response. Put differently, a key difference between wetware and hardware-software is that wetware entails the sort of structures, processes, and mechanisms that can produce a placebo response.”

Placebo response in this context is not a bug, not some pesky feature of our psychology that merely makes it difficult for researchers to conduct successful RCTs. Rather, it becomes an essential characteristic of our embedded, embodied, and enactive selves! I never thought of it that way.

: The Turing test, which asks that we interact with a computer, and decide whether it is a person or machine, is well-known. Stevan Harnad, PhD, has rigorously put forward variations of the Turing test, which help think through distinctions between humans and computers. For example, once robots can move around a room, and say dance with us, it becomes harder to distinguish persons from machines. Thinking about these issues as a psychopharmacologist, I was struck by the idea that even if machines can move and dance, there is yet another a level of human interaction that is captured by the placebo response, and that then helps us with distinguishing humans from machines. I am not sure that non-psychopharmacologists will find this the best way of arguing that human cognitive-affective processes are embodied and embedded, and so I particularly appreciate your being enthusiastic about this idea!

: At one point you write, “What about the fact that much psychotherapy is aimed not at specific mental disorders, but rather at ‘problems of living’? Can we really make progress in providing help for this sort of issue?”

 I think you are right that a lot of psychotherapy is aimed at problems of living, but it seems to me that a lot of contemporary pharmacotherapy is also aimed at problems of living, especially the use of SSRIs in primary care settings for the treatment of depression, anxiety, stress, etc. According to the Centers for Disease Control, between 2015 and 2018, 

 were prescribed an antidepressant medication!

 It just does not seem that way because we are able to hide the distress and impairment behind all sorts of diagnostic labels. I am not taking the extreme Szaszian view here that all psychiatric disorders are problems of living, but more of a gentle skeptical view that there is no natural distinction to be found. Would you agree with that?

: Your point that both psychotherapy and pharmacotherapy address problems of living is a trenchant one. And I am with you with regards to a gentle skeptical view that there is a spectrum from psychiatric disorders through to problems of living, and my sense is that this is increasingly recognized both in neuroscience (eg, in the Research Domain Criteria framework) and in global mental health (which often speaks of the spectrum from illness to health). In 

, I often turn to Aristotle. I trust we are better at treating bipolar disorder than the ancient Greeks, but I suspect that the ancient Greeks were as good as helping individuals with problems in human relationships as we are, demonstrating the sort of practical wisdom (

) that is required in medicine and psychiatry. Although advances in obsessive compulsive disorder inspired me to go into that field, and although I am proud of the ongoing progress the field has made, I suspect that Aristotle and his physician father would have some good techniques up their sleeves to manage some quite serious mental illnesses. Certainly, Aristotle’s thinking about mental disorders is sometimes very prescient.

: As I was reading your discussion of metaphors, I thought of 2 things. The first is a quote by Derek Bolton, PhD, and Grant Gillett, MSc, DPhil, from their book on the biopsychosocial model, a work you cite as well. They write at 

: “What is missing from and obscured by these two-dimensional picture metaphors of levels and nested domains is the temporal, evolutionary and developmental, parameter… no static metaphor, whether in terms of levels or nested systems, capable of being drawn on a page, does justice to the new systems sciences, which essentially invoke dynamical interaction in present time, on the basis of co-evolution through deep time.”

 De Haan has a wonderful ability to illustrate her arguments using metaphors. She has talked about vulnerability to mental illness using the metaphor of laying down 

: “once there is this path it is so much easier to walk that road again rather than go through all the trouble and hard work of making a new path. We slip into old patterns because they have become so engrained and come so naturally. Vulnerability is like having deeply engrained paths, making relapse probable, yet we are not destined to walk them.”

 One of her most delightful metaphors is that when we think of minds, we should “think cakes, not clockworks.” At the same time, like yourself, she argues that metaphors are never innocent and require eternal vigilance.

I think these 2 instances show us the power of metaphors to constrain us as well as liberate us. Our historical understanding of biopsychosocial complexity has been constrained by static metaphors, while new metaphors (such as baking a cake as a metaphor for organizational causality) free us from old mechanical ways of thinking. What is your view on the use of metaphors in philosophy and psychiatry?

: Dr Bolton co-supervised my dissertation in philosophy, and I am a fan of his work as well as of enactive approaches to psychiatry. I fully agree with your view that metaphors can constrain as well as liberate us. I have been interested in how metaphors work in our distinctions between typical and atypical disorders. In a typical disorder, metaphors such as being 

 work well: someone with pneumonia is attacked by a bug, we fight back with a drug, and they are not blamed but rather deserve the sick role. However, in an atypical disorder, these metaphors work less well: someone with alcoholism is not simply attacked by an external agent, rather they have to take some responsibility for their illness, and there is debate about the extent to which they deserve the sick role. It is as if we shift from medical to moral metaphors for conditions such as alcoholism. So, I like the idea of metaphors of addiction that bridge the medical and moral in order to avoid blame, but also to emphasize responsibility. It is also interesting to me that we use the metaphor of 

 for thinking through healthiness and goodness, and indeed Aristotle and other writers of the Axial Age appropriately emphasized the importance of the golden mean, of moderation, and of balance.

: Your experiences with professors of psychoanalytic orientation vs those of neurobiological and nosological orientation during your psychiatric residency seem to have left a deep mark on you. I have observed that the biological psychiatry vs psychoanalysis divide was often thought of as the central schism of the field by several of my psychiatric professors as well. Fortunately, this schism has played less of a role in my own education. One of the features of the biological psychiatry vs psychoanalysis divide was that it was very much an internal schism, a divide within the psychiatric community. The notable schisms that I think our field is confronting now are between quite different players. Schisms between so-called 

 technological approaches (pharmacotherapy, CBT, etc) vs existential-humanistic-psychodynamic approaches; biomedical models vs interpersonal-relational models; and the epistemic authority of medical professionals vs epistemic authority of users of psychiatric services (exemplified by movements such as neurodiversity, mad pride, service user/survivors/ex-patients, etc). 

My approach to these schisms is in alignment with the same pluralistic and integrative approaches that you adopt. However, a concern increasingly comes up when I discuss these things: within a pluralistic-integrative framework integrating these polarities, it is no longer obvious that psychiatry as a medical profession—that has increasingly specialized in psychopharmacology and clinical neuroscience over the last 3 decades—serves as the suitable umbrella profession for the integrated domain, instead of, say, clinical psychology, or social work, or even efforts led by service users. If neuroscience and psychopharmacology will no longer be of central importance in the new pluralism (at least it’s not obvious), then why should psychiatry continue to claim its existing power? This is also a point that 

 with me: “I am a deep believer in pluralism, too, but I believe that a road to true pluralism will require the courage to share power. In other words, alongside becoming less reductionist, the field also could consider becoming less hegemonic… I have suggested that the field would be stronger and serve patients better if it functioned as one part—the medical part—of a cooperative ecosystem of mental health experts.”

: I agree with you about the importance of the schisms that you mention (my sense is that these partly reflect aspects of the biological-psychoanalytic schism), and I am glad that you are in alignment with pluralistic and integrative approaches to addressing them. In 

, I emphasize the importance of epistemic humility and of owning our fallibility; so absolutely we need to be open to entirely new ways of explaining, understanding, and improving mental health. Certainly, mental health is too important to be left to psychiatrists. My work on trichotillomania has clearly taught me how much service users know, and how valuable they are in creating solutions. At the same time, I would want to appropriately acknowledge the breadth and depth of psychiatry. So, with regard to sharing hegemony, I may be a bit more conservative than you would like. In my book, I refer a few times to the work of Jonathan Haidt, PhD, who as you know has argued for diversity of political positions; I do wonder if greater balance between conservativism and progressivism in general may not be useful, as we move forwards.

: What do you see as some of the challenges we face in the pursuit of an integrative and pluralistic approach to psychiatry, and how can psychiatrists, especially trainees, better prepare for these challenges ahead?

: Another great question, from your columns I know you have a knack for making thinkers think harder! In line with my view that despite its important limitations, psychiatry does have extraordinary breadth and depth, I would argue that our field does already exemplify explanatory pluralism, and that a good clinician is necessarily taking an integrative approach. I do think that explicitly providing residents conceptual frameworks, as you have advocated for, is a good idea; this might be useful in seeing the explanatory pluralism we use as something to be proud of rather than concerned by. I do think that explicitly providing residents with exposure to good clinicians and researchers, who are able to explain how they integrate different ideas and approaches, is useful. Finally, although I appreciate that it is important to be hopeful about the future, I also think that more explicit humility might be helpful at times; in our understandable zeal to address suffering, we may run the risk of overselling what we can do with any particular treatment approach, or any particular research program. In sum, I go back to a favorite metaphor: a balanced approach is key!

is a psychiatrist in Cleveland, Ohio, and clinical assistant professor of Psychiatry at Case Western Reserve University. He is a member of the executive council of Association for the Advancement of Philosophy and Psychiatry and has been actively involved in initiatives to educate psychiatrists and trainees on the intersection of philosophy and psychiatry. He is also a member of the 

Dr Aftab has no relevant financial disclosures or conflicts of interest. Dr Stein discloses that he has received research grants and/or consultancy honoraria from Johnson & Johnson, Lundbeck, Servier, and Takeda.

1. Stein DJ, Phillips KA, Bolton D, et al. What is a mental/psychiatric disorder? From DSM-IV to DSM-V. 

2. Stein DJ. Psychiatric contributions from South Africa: ex Africa semper aliquid novi. 

3. Kendler KS, Campbell J. Expanding the domain of the understandable in psychiatric illness: an updating of the Jasperian framework of explanation and understanding. 

5. Brody DJ, Gu Q. Antidepressant use among adults: United States, 2015-2018. The Centers for Disease Control and Prevention. September 2020. Accessed June 28, 2021.

6. Bolton D, Gillett G. The biopsychosocial model 40 years on. In: 

The Biopsychosocial Model of Health and Disease: New Philosophical and Scientific Developments

8. Aftab A. Sense-making and the enactive turn in psychiatry: Sanneke de Haan, PhD. 

. October 22, 2020. Accessed June 28, 2021.

9. Aftab A. The many histories of biological psychiatry: Anne Harrington, DPhil. 

Travelling the middle road between skepticism and scientism in psychiatric research and treatment.  

From Classic and Critical to Integrative Psychiatry: Dan J. Stein, MD, PhD, DPhil

With Sigmund Freud’s development of modern psychotherapy in the 1890s, a new method for treating psychopathology was born. A neurologist by training, Freud was first and foremost a medical doctor who, in 1895, wrote that with psychoanalysis he wished to create “a psychology that would be a natural science.”

 Throughout his career, Freud maintained his belief that future advances in neuroscience would validate his ideas on the unconscious, and that later modifications to psychoanalytic technique could render it effective for more severe mental diseases like schizophrenia.

Yet, in the past 50 years, and especially the past 30, we have witnessed the concept of 

 applied to a host of endeavors unrelated to the treatment of psychopathology. These fields include marital, family, and relationship therapy; career and corporate counseling; positive psychology and general self-improvement; new age energy healing; and, most recently, life coaching. It is conceivable that the current number of therapists in the United States working in areas such as those listed previously exceeds the number of therapists interested primarily in the treatment of psychiatric disorders.

The American Psychological Association’s 

“…any psychological service provided by a trained professional that primarily uses forms of communication and interaction to 

 dysfunctional [disordered] emotional reactions, ways of thinking, and behavior patterns.”

Yet, among some modern psychoanalysts and existential therapists, there is a tendency to see psychotherapy as a process wholly unrelated to the concept of mental illness (ie, not as a form of treatment for illness, but rather as an endeavor undertaken for other reasons), a position that deviates significantly from the psychiatric and psychoanalytic conceptualization of psychotherapy for the vast majority of the 20th century.

While this demedicalization of psychotherapy coincides chronologically with the growth in lay analysis (ie, the practice of psychotherapy by nonphysicians), I contend that it is not solely due to this factor. Psychiatric social workers were the first nonphysicians to practice psychotherapy beginning in the early 20th century, engaging in this practice well before it was adopted by the fields of psychology and counseling, but psychotherapy remained chiefly focused on the treatment of the mentally ill during this period.

 Rebranding psychotherapy as a nonmedical endeavor unrelated to 

 has come with numerous negative consequences.

The Consequences of Demedicalization for Patients

I contend that there are 3 main consequences to demedicalizing psychotherapy:

1. Psychotherapy becomes devalued relative to other forms of psychiatric treatment, despite its proven effectiveness for a range of mental disorders.

2. Access to psychotherapy as a treatment for mental disorders becomes more difficult, as fewer therapists choose to specialize in treating psychiatric patients and instead become focused on other forms of therapy or counseling.

3. Training requirements for psychotherapists continue to loosen, so that many graduating therapists have had little to no exposure to patients across the psychiatric diagnostic spectrum.

While all 3 points are vital, I wish to comment briefly on number 3, which I see as particularly worrisome. Training standards for psychotherapists in this country have been falling for decades. For instance, some clinicians finish graduate school without ever having assessed a patient with schizophrenia or 

. Internship sites may be located in a variety of nonclinical settings. Without adequate training in the assessment and treatment of mental disorders, nonmedical therapists are less likely to choose to work with these patients—and may put them at risk of harm if they do.

These factors have led to a shortage of properly trained psychotherapists nationwide. In my own metropolitan area of over 3 million individuals, there are only a handful of therapists in private settings who work with patients with severe mental disorders, such as 

. Yet, the online therapy directories are filled with listings of therapists who specialize in relationship problems and life coaching. The sad reality is that the patients who need the most help are the ones least likely to find it. The 

 of psychotherapy becomes a barrier to access of competent mental health care.

In saying that psychotherapy is primarily a form of medical treatment, I am not suggesting that its practice once again be limited to physicians. In a broad sense, a whole host of medical interventions are provided by nonphysicians, such as nurses and physician assistants, and I contend that psychotherapy is one of those interventions. As noted above, psychiatric social workers practiced psychotherapy within departments of psychiatry starting in the 1910s. During this time, psychotherapy remained a medical treatment for psychiatric disorders.

Likewise, I do not contend that these nonmedical extensions of psychotherapy, such as helping businesspeople climb the corporate ladder, are not legitimate activities that serve a useful purpose. It is simply to say that these other enterprises, as worthy (and lucrative) as they may be, distract us from psychotherapy’s main goal: the alleviation of the human suffering caused by mental illness. What we are left with is a psychotherapy that works for the rich and healthy, not the sick and disabled.

The Consequences of Demedicalization for the Field of Psychotherapy

Not only is demedicalizing psychotherapy bad for psychiatric patients, it is also bad for psychotherapy itself. When psychotherapy is seen by the general public—and by some mental health professionals—as something other than treatment (eg, as mere conversation to deal with day-to-day life struggles), it becomes an intervention of secondary or tertiary importance in the psychiatric armamentarium. If psychotherapy is seen as not really treating mental disorders (“Medications treat the illness, psychotherapy just helps people cope”), then its use will gradually fall out of fashion in favor of other, usually biological, treatments. Yet we know that psychotherapy is the treatment of choice for a range of mental disorders, including personality disorders, posttraumatic stress disorder, mild depressive disorder, and others.

Even in instances where psychotherapy is not indicated as monotherapy, such as in the treatment of bipolar disorder or schizophrenia, its use is not merely supportive in nature and it still reflects a form of treatment. When conceptualized through a biopsychosocial lens, even complex diseases like schizophrenia possess a psychosocial component, and psychotherapy can legitimately be seen as 

While much of the demedicalization of psychotherapy has been the result of harmless motives, there is also an antipsychiatry push to conceive of psychotherapy as something other than treatment. This line of argument goes something like: “Mental illness does not exist and thus psychotherapy does not treat illness.” Szasz made such an assertion in his 1978 book 

 but his conclusions were based on a faulty interpretation of the concept of disease.

 One need not be a psychotherapist, or even place much stock in psychotherapy, to see the problems inherent in this line of reasoning.

Lastly, conceptualizing psychotherapy as a medical treatment does not necessitate or imply a theory of biological causation of psychiatric disorders. The psychoanalysts of mid-century American psychiatry certainly viewed psychotherapy as treatment in the literal sense, but few saw psychiatric disorders as biological diseases. While a thorough discussion of the meaning of “disorder” in psychiatry is well beyond the scope of this paper, it suffices to say that one can conceptualize mental disorders as bona fide medical diseases due to their associated suffering and incapacity

 regardless of any known or imputed biological abnormality.

Freud’s original aim for psychoanalysis was as a method for treating mental illness. Psychotherapy remained, for many decades, primarily a form of medical treatment, even when practiced by nonphysicians. Attempts to define analysis—and, by extension, psychotherapy—in other ways deviate historically from its original and primary intention. The more recent application of psychotherapy to problems unrelated to psychopathology dilutes the value of psychotherapy, loosens training requirements, and leads unnecessarily to barriers to care.

is Instructor of Psychiatry at the University of Central Florida College of Medicine in Orlando, FL, and Adjunct Instructor of Psychiatry at Tufts University School of Medicine in Boston, MA. He is a psychoanalytic psychotherapist in private practice.

. Standard Edition. Hogarth; 1966:295-397.

2. American Psychological Association. Psychotherapy. APA Dictionary of Psychology. Accessed June 20, 2021. 

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