Glosses and Bootstrapping: 2 Strategies for Innovation in Psychology, Psychiatry, and Psychotherapy

SECOND THOUGHTS

When asked about the difference between analytical (Anglo-American) and Continental philosophy, Italian semiotician and philosopher Umberto Eco offered an analogy from the history of philosophy. Medieval philosophers (the Scholastics or so-called “Schoolmen”) were “continually innovative but they tried to disguise any innovation presenting it as a gloss, a commentary of a unified tradition.” On the other hand, “modern philosophers like Descartes were pretending to start from a ‘tabla rasa’ – a blank slate – by putting the previous positions upside down and polemically casting it in doubt.” Eco concludes, “this is more a difference of philosophical style than on a different set of contents or methods.”¹

As a philosopher of the “psy disciplines” (psychology, psychiatry, and psychotherapy), I agree with Eco and believe that it applies to our work in that innovation in our field comes down to glosses on a tradition vs creating a new one. My gloss on his insight is to add a twist to the blank slate approach—theorists are often motivated by a wish to create something new, to found a tradition sui generis that I call “bootstrapping.”

The stakes between the 2 concern how we imagine innovation in our field which comes down to continuity vs discontinuity. Glosses represent continuity with tradition while the blank slate or bootstrapping approach represent a rupture or radical break with those traditions. Applying this to our field, we can name some approaches that argue for glosses on a tradition and those that argue for bootstrapping from scratch:

• Glosses: all the varieties of psychotherapy based on the Freudian legacy of psychanalysis and psychodynamic psychotherapy.
• Blank slate or bootstrapping: behavior therapy, cognitive therapy, and family therapy presented themselves as radical departures, criticizing and discrediting past approaches.

Glosses

There is nothing new under the sun.

– Ecclesiastes 1:9

In academic scholarship, glosses are annotations or footnotes to the main text or interpretations and paraphrases of a text. This approach proceeds by adding nuances, clarifications, details, specifiers in the DSM, or new applications of an established model.

The ultimate example of this in philosophy is what Alfred North Whitehead said about Plato²:

The safest general characterization of the European philosophical tradition is that it consists of a series of footnotes to Plato.

We can adapt this to the world of psychotherapy to say that the Western therapeutic tradition consists of a series of footnotes to Freud. Franco-Canadian psychiatrist and historian Henri F. Ellenberger, MD, sees Freud’s “discovery of the unconscious” as the foundation of dynamic psychiatry,³ whereas I would qualify it as a social construction in the sociology of knowledge. César Alfonso, MD, the president of World Federation for Psychotherapy, claims that there are 4 thousand kinds of psychotherapy worldwide. I tend to think that in the Western tradition, most of these psychotherapies are offshoots of the Freudian legacy, including the additions, clarifications, and technical modifications of Freud’s psychoanalytical model. A long but far from exhaustive list would include: Otto Rank; Vicktor Tausk, MD; Sándor Ferenczi, MD; Paul Federn; Karl Abraham, MD; Wilhelm Stekel, MD; Wilhelm Reich, MD; Theodore Reik; and Carl Jung, MD; to Alfred Adler, MD, not forgetting the British schools from John Bowlby, MD, and the 3 Tavistock schools—Anna Freud; Melanie Klein; and Donald Winnicott, MD; and RD Laing, MD, as their critical offspring—to Wilfrid Bion, MD. We can add the French schools from Jean Laplanche, MD, and Jean-Bertrand Pontalis, MD, to Jacques Lacan, MD; the Italians from Edoardo Weiss, MD, and Roberto Assagioli, MD, to the current champion of Bion and field theory in psychoanalysis, Giuseppe Civitarese, MD, PhD.⁴ And finally, the North American schools from the neo-Freudians like Harry Stack Sullivan, MD; Erich Fromm; and Frieda Fromm-Reichmann, MD; at the William Alanson White Institute with its interpersonal approach to Karen Horney and Heinz Kohut up to Robert Langs, MD, James Grotstein, MD, and Stephen Miller’s relational psychoanalysis.

Those are just some of the established and respected branches but we may name other branches, such as Eric Berne, MD’s transactional analysis (made famous in his Games People Play,⁵ that inspired 2 highly successful songs by Joe South and The Alan Parsons Project), Arthur Janov’s primal scream therapy (made famous by John Lennon and Yoko Ono, who underwent his therapy and integrated it into their music and art), Rolfing that its founder Ida Rolf called structural integration, and as many other varieties as there are waves on Venice Beach. And now, many varieties of psychotherapy are based on the itch that Freud started to scratch.

We may conclude that Freud’s influence moved beyond a foundational figure to what W.H. Auden declared in his memorial poem⁶:

to us he is no more a person

now but a whole climate of opinion

To be sure, there are other approaches in Alfonso’s survey of 4 thousand psychotherapies in the world, many of them outside the Freudian legacy or the Western tradition.

As I wrote in a previous column on global social psychiatry, non‑Western and Eastern models challenge Western I-centered assumptions, including: J.S. Neki, MD’s Gurū–Chelā (teacher–disciple)⁷ relationship as a form of indigenous Indian psychotherapy, Morita therapy from Japan, and Buddhism and mindfulness traditions from Asia. To these we may add curandero and native or traditional healers around the world. A special case is the mambos and onguns of Haitian Vodoun and their variations throughout the African diaspora from santeria in Cuba to candomblé in Brazil. I see them as glosses on the religions and traditions of West Africa, notably in Nigeria.

In light of this rich palette of interventions, the psychotherapy world is screaming out for its Linnaeus—or perhaps closer to home, its Emil Kraepelin, MD—to bring some order to this riot of therapeutic invention.

Bootstrapping

Examples of bootstrapping that abound in the psy disciplines are more straightforward because they announce their radical departures more clearly. These approaches, which declare a break with the past, starting from scratch to write on a blank slate, start with the canonical example of behavior theory and therapy, originating in American psychologist J.B. Watson’s behaviorist manifesto of 1913.⁸ Cognitive therapy and its variations—cognitive-behavioral therapy (CBT) and dialectical behavior therapy (DBT)—has become the new gold standard of therapy in many places, while family therapy, often joining the antipsychiatry movement, presented itself as a radical departure, discrediting past approaches, notably the I-centered approaches and psychiatric diagnosis.

Closer to our time, the strongest example of bootstrapping in psychiatry occurred at the National Institute of Mental Health (NIMH) where Thomas R. Insel, MD, the director from 2002 to 2015, wagered on biological aspects of psychiatry—neuroscience and genetics—in the spirit of President George H.W. Bush’s designation of the “Decade of the Brain” (1990-1999). In a recent column based on a talk I gave in India on why Western psychiatry is shackled by its sacred cows and shibboleths, I identified the reduction of mind to brain as one of the shibboleths of Western psychiatry. Insel proposed NIMH’s Research Domain Criteria (RDoC), offering a biologically based diagnostic framework in contrast with the American Psychiatric Association (APA)’s symptom-based DSM, which he colorfully dismissed as a “mere dictionary.”⁹

Yet, the problem is deeper than dismissive bootstrapping: reducing mind to brain depreciates not only a symptoms framework but lived experience across many other domains—from behavior, cognition, and relations to social determinants of health. Insel’s RDoC framework dismisses more than 200 years of work in psychiatry, including such German pioneers as Emil Kraepelin, MD (dementia praecox), his student Eugen Bleuler, MD (schizophrenia), and an entire school of work that followed from Kurt Schneider, MD (First Rank Symptoms of schizophrenia) in Germany to John Feigner, MD, and his colleagues at the Washington School in St. Louis, MO, who developed the Feighner Criteria, which grew into the Research Domain Criteria (RDC).¹⁰

The danger, as ever, with the bootstrapping approach was articulated by Swiss psychiatrist and medical historian Paul Hoff, MD: “a serial collapse into single message mythologies”¹¹ where we see radical departures with strong claims and harsh critiques of past approaches, without valuing and retaining useful elements of previous techniques.

Counter Examples: Syntheses

My undergraduate professor of psychology at McGill, Donald Hebb, who was a pioneer in neuropsychology, famous for his “cell assemblies” and the slogan, “Cells that fire together wire together,” declared that the future of psychology depended on deviating from what common sense would approve of. He was true to this and certainly took psychology in new directions and—along with Brenda Milner in psychology and Wilder Penfield, MD, in neurology and neurosurgery at McGill—was a founder of today’s neuroscience.¹²

It is tempting to call Hebb’s approach a break with the past to create a radical new direction. It was unquestionably a fresh theory that opened up a whole field of neuroscience research with a different approach to the age-old question of “mind” by adding the brain. Yet, that was only radical to the extent that it criticized and rejected the Freudian legacy. When I asked Hebb why his introductory course did not mention Freud and other approaches to understanding human behavior, he replied that a survey course would be superficial and that he preferred to offer a view of psychology standing in one place and offer a coherent view of psychology based on his theory.

In fact, Hebb’s seemingly radical departure had roots in learning theory, including his own research in animal learning at the Yerkes Laboratory, and the early pathbreakers in neuroscience from Spanish Santiago Ramón y Cajal, MD, and Italian Camillo Golgi, MD, on the structure of the nervous system for which they won the Nobel Prize in Physiology or Medicine in 1906, and Dutch-American neuroanatomist Walle Nauta, MD, to Portuguese neurologist António Egas Moniz, MD, another Nobelist in 1949.

In light of this major example in psychology and neuroscience, we may conclude that we need more integrative syntheses of what has been applied in the past instead of bootstrapping. CBT was one such attempt, integrating cognitive components to the longstanding tradition of behavior therapy with roots in J.B. Watson’s behaviorist manifesto of 1913.⁸ David Schnarch’s bringing together couple therapy with sex therapy is another key example.¹³ While the philosophical basis for Viktor Frankl, MD’s logotherapy is fresh and different from previous approaches with its emphasis on meaning, many of the actual techniques are much like behavior therapy and are coherently explained through behavior theory.¹⁴ Finally, in social psychology, American social psychologist Harold Kelley’s attribution theory¹⁵ synthesized the findings of Leon Festinger’s cognitive dissonance theory¹⁶ into a more comprehensive and predictive framework.

In 2012, I attended the opening session at the APA Annual Meeting in Philadelphia of a dialogue between Aaron T. Beck, MD, and Glen O. Gabbard, MD, moderated by APA President John Oldham, MD, where they found common ground.¹⁷ It made me think of the title of Leonard Cohen’s first book of poetry entitled, Let Us Compare Mythologies.¹⁸ We heard these 2 pillars of therapy in American psychiatry talk about how they created their own mythologies. Both highly successful and impactful, they nevertheless came together late in their careers to acknowledge the roots of Beck’s cognitive therapy in psychodynamic psychotherapy on one side and the similarities of Gabbard’s psychodynamic psychotherapy with the cognitive restructuring of Beck’s approach.

Needed: A Theory of Change

The history of psychiatry rewrites itself so often that it almost resembles the self-serving chronicles of a totalitarian and slightly paranoid regime. One-time pioneers are suddenly demoted and deemed to be little more than package tourists.

– British novelist, J.G. Ballard¹⁹

Ballard holds up an embarrassing mirror to our episodic, partisan, and sometimes chaotic history, bouncing from one enthusiasm to another, ever hopeful, ever disappointed. One of my critiques of the state of academic psychiatry is that we cannot even take stock of these episodes because we do not have a theory of change, leading to a crisis. To put it otherwise and more colloquially, we lack an explanation of how new things come into the world. Psychiatry has neither a consensual and unifying theory of change nor a philosophy of our field that can undergird its foundation. That leaves us tottering from one approach to the next, as Ballard observed, and we invent ad hoc theories of the person (psychology), of the nature of therapy, and of change. To be sure, we have many competing theories but no unifying consensus among them.²⁰

We may well need both philosophical strategies—integrating and synthesizing the best of the past along with new departures for radical innovation. And yet, the best way to genuine innovation is to understand what the existing approaches already have to offer rather than serving old wine in new bottles. As Bob Dylan sang in “A Hard Rain’s A-Gonna Fall” in 1963,

But I’ll know my song well before I start singin’.

Resources

Among the many histories and overviews of the psychotherapies, I would recommend the following sources for an overview of the evolution of psychotherapy in its various guises:

• Henri F. Ellenberger. The Discovery of the Unconscious: The History and Evolution of Dynamic Psychiatry. Basic Books; 1970.
• Jeffrey K. Zeig, ed. The Evolution of Psychotherapy. Brunner/Mazel; 1987.

Proceedings of the first conference organized by Jeffrey Zeig in Phoenix, Arizona in 1985, described as the “Woodstock” of psychotherapy.

• Jeffrey K. Zeig, ed. The Evolution of Psychotherapy: The Second Conference. Routledge; 1992.
• Jeffrey K. Zeig, ed. The Evolution of Psychotherapy: The Third Conference. Routledge; 1997.

Mark L. Ruffalo, MSW, DPsa, a frequent Psychiatric Times columnist, writes informative articles about psychotherapy, psychiatry and psychopathology that are well worth reading.

• Mark L. Ruffalo. Special report: Psychotherapy. Toward a new psychiatric pluralism: The resurgence of psychotherapy. Psychiatric Times. 2025;42(7).

Dr Di Nicola is a child psychiatrist, family psychotherapist, and philosopher in Montreal, Quebec, Canada, where he is professor of psychiatry & addictology at the University of Montreal. He is also clinical professor of psychiatry & behavioral health at The George Washington University and past president of the World Association of Social Psychiatry (WASP). Dr Di Nicola has received numerous national and international awards, honorary professorships, and fellowships. Of note, Dr Di Nicola was elected a Fellow of the Canadian Academy of Health Sciences (FCAHS), given the Distinguished Service Award of the American Psychiatric Association (APA), and is a Fellow of the American College of Psychiatrists (FACPsych) and Fellow of the Royal Society of Canada (FRSC). His work straddles psychiatry and psychotherapy on one side and philosophy and poetry on the other. Dr Di Nicola’s publications include: A Stranger in the Family: Culture, Families and Therapy (WW Norton, 1997), Letters to a Young Therapist (Atropos Press, 2011), and Psychiatry in Crisis: At the Crossroads of Social Sciences, the Humanities, and Neuroscience (with D. Stoyanov; Springer Nature, 2021).

Acknowledgements

I am grateful to readers of the first draft of this column for their helpful comments: John Farnsworth, PhD; Dennis Palumbo, MA, MFT; Bart Blinder, MD; Brian Greenfield, MD; and Mark Ruffalo, MSW, DPsa.

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