How can psychotherapy become a mature science?
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.
Awais Aftab, MD
Dr Goldfried is distinguished professor of Clinical Psychology at Stony Brook University, NY. He is cofounder of the Society for the Exploration of Psychotherapy Integration. He is a Past President of the Society for Psychotherapy Research and has received numerous awards and honors, including the American Psychological Association (APA) award for Distinguished Contributions to Knowledge. He has authored and co-edited several books, including the third edition of Handbook of Psychotherapy Integration (Oxford University Press, 2019, co-edited with John C. Norcross).
Marvin R. Goldfried, MD
Dr Goldfried’s work in psychotherapy integration and common principles of change has been of great fascination to me. The central idea behind psychotherapy integration is that there are common principles, shared change processes, that transcend particular theoretical orientations in psychotherapy, and account for the effectiveness of many different psychotherapeutic interventions. I am grateful for his presence on twitter, which has allowed many such as myself to be exposed to his rich ideas and his vision for a mature science of psychotherapy. As a psychiatrist with an interest in psychotherapy, I find these developments to be of great relevance to all psychiatric clinicians. Allen Frances, MD, who introduced me virtually to Dr Goldfried, first met him when they served together, 40 years ago, on the National Institute of Mental Health (NIMH) committee that funded the early studies of cognitive behavioral therapy (CBT) and dialectical behavior therapy (DBT). Dr Frances is convinced that the few millions of dollars spent on psychotherapy research have done far more to improve patients’ lives than all the tens of billions since spent by NIMH on neurobiological research, which has offered some fascinating insights but has yielded little of clinical benefit so far. “Marvin's career-long effort to integrate the various schools of psychotherapy, and to establish what is most essential to successful outcome, is the wave of the future in psychotherapy practice and research” (personal communication with Dr Frances, October 2020).
Aftab: You write in an article of yours that “although the field of psychotherapy has been in existence for well over a century, it nonetheless continues to be preparadigmatic, lacking a consensus or scientific core. Instead, it is characterized by a large and increasing number of different schools of thought.”1 Although you are talking specifically about psychotherapy, I feel it would not entirely be inaccurate to generalize this to the mental health professions at large. Ken Kendler described psychiatry somewhat similarly in American Journal of Psychiatry: “Kuhn argues that to be considered a mature science, a field has to agree on a basic scientific paradigm. Psychiatry, by this criterion, would be in an immature ‘preparadigmatic’ state.”2 I personally find the realization that we are still in preparadigmatic state to be rather sobering. It cuts through a lot of the bravado that we see around us. I think as long as we remain in a situation where mutually antagonistic, non-interacting theoretical camps are fighting with each other for dominance and resources, we are not likely to see a maturation of the field. You have written much about psychotherapy, and we will discuss that shortly, but do you have any thoughts on the overall state of the psy-professions?
Goldfried: Sociologists who studied the scientific enterprise originally thought the scientist was a totally objective and neutral being. Actual research on scientific behavior has discovered, however, that because scientists were individuals before they were scientists, strong emotions often come into play in their work. It has been clearly documented that scientists compete with each other in various ways. Publishing first is traditionally the goal. It has even been documented that citation practices are selective, and that researchers cherry-pick evidence to support their particular point of view.
Unlike fields in physical medicine, where it is clear whether somebody has a fever or not, or whether they have recovered from a major illness, psychology and psychiatry often have difficulty in agreeing upon criteria for change, ie, the criteria used to conclude that the therapy has worked. For instance, what does it mean that someone has been successfully analyzed? The criteria are often influenced by theoretical schools, and it is hard to get a consensus across theoretical orientations as to whether the treatment has worked.
Aftab: You write, “Unfortunately, depending upon whether one is a clinician or researcher, each tends to think that his or her method of advancing the field is superior. The fact of the matter is that both are flawed, and, therefore, they both need to be complemented by the other vantage point.”3 I think there is a similar sort of a gap in psychiatry as well, albeit with its own distinct characteristics. I am reminded of something Peter Kramer wrote, “[Instead of] a dichotomy—refined research, which gets at the facts, versus anecdotes, which are often misleading—I saw a spectrum on which sit flawed efforts at objectivity.”4 What do you see as the appropriate relationship between research and clinical practice?
Goldfried: Within the United States, World War II created a major shift in who delivered psychotherapy. The psychological problems manifested by soldiers required therapy, and the problem was that there were relatively few psychiatrists to meet the very large demand. Consequently, at the end of the war, the NIMH and the Veterans Administration decided that it would be appropriate to train psychologists in the practice of therapy. They had previously been trained as research scientists, with clinical applications consisting primarily of testing. The net result was the development of the scientist-practitioner model, where professional psychologists would train as both researchers and practitioners.
Although the goal of being both a scientist and practitioner was admirable, it has not often played out that way. Consequently, we have researchers who rarely see patients, and clinicians who rely on their theory and clinical experience rather than research. However, if a phenomenon is recognized by clinical observation, and it also has empirical support in the research, I think it has a greater likelihood of being true. Research methodologists call these “converging operations,” where different methods of inquiry are used to study a given phenomenon.
Philosophers of science also make a distinction between the context of discovery and the context of justification. Clinical work can be a context of discovery, where phenomena are observed subjectively, and research then becomes the context of justification, where the researcher attempts to see if the phenomenon exists under conditions of better experimental control.
Aftab: In line with the previous question, you have talked about how the gap between psychotherapy research and practice has been a long-standing source of professional distress for you. How have you navigated this gap in your own career as both a clinician and a researcher?
Goldfried: I have always been dedicated to both research and clinical practice and have managed to do both throughout my career. When we established the clinical psychology program at Stony Brook University back in the 1960s, we constructed it in such a way that faculty members would not only teach and do research, but also serve as clinical supervisors. For myself, I see patients on Tuesdays and often use my clinical observations as examples on Wednesdays and Thursdays when I am working at Stony Brook.
I have experienced situations where what I observed in the clinical situation provided me with hypotheses for conducting research. For example, take the use of systematic desensitization involving both imaginal exposure and relaxation. Some research pointed out that both were necessary in order to be effective. On the basis of my clinical observation, however, some patients were finding relaxation skills alone useful. Apparently, they did not read the research literature! It turned out that in their view, relaxation was not just something that would be a passive activity. It could be used as an active coping skill as well. Consequently, I conducted some research on the issue and demonstrated that a coping skill orientation to relaxation was more effective than treating relaxation as a passive exercise.
Aftab: Your comments about clinical work providing hypothesis for research is certainly important and resonates with me a lot. I really like something you said once in a conversation with George Stricker, “Some very astute observer once noted that research ideas that are born in the literature are destined to be buried in it. Really good researchers know that informal, direct observation is the context of discovery, in which important research questions are born.”5 This remark has stayed with me ever since I read it! I am also, however, curious about the inverse relationship, the way research informs clinical practice. In your writings you have described a formative encounter with Paul Meehl during your graduate training.3 You asked him about the extent to which his clinical work was informed by research, and his unhesitant reply was “Not at all,” which left you quite disheartened. If a trainee were to ask you that question now, what do you think your response would be?
Goldfried: I would say that research definitely informs what I do clinically. Basic research on cognition, emotion, behavior, and social psychology tells me how individuals function. Research on psychopathology provides me with mediating and moderating variables, which I may need to attend to when working with a given patient. Therapy process research addresses the question “What did the therapist do to make an impact?” It informs me on what I can do to make an impact.
I have mixed feelings about clinical trials and have critiqued them in past articles I have written.6 I think the use of a medical model to conduct outcome research on interventions took a wrong turn when it targeted heterogeneous DSM disorders. I found the previous model of outcome research much more helpful, such as those studies that focused on clinical problems of as unassertiveness and procrastination.
Aftab: You have been a big proponent of moving from theoretical orientations to principles of change. At a midlevel of abstraction between theory and technique, it is possible to consider principles of change that are common to most forms of therapy, despite their very different theoretical underpinnings. Can you elaborate on what you mean by that? And can you give an example of a common principle being described differently by different orientations?
Goldfried: I think the important thing about transtheoretical principles of change is that they have managed to manifest themselves despite varying theoretical orientations. Given the fact that one’s theoretical school of therapy provides a certain way of understanding a phenomenon conceptually, when a phenomenon emerges across different orientations, I consider it very robust.7 This is much like the case of clinical phenomena that result from both clinical observation and empirical research.
One such example is the corrective experience. This can occur within the therapeutic interaction, as indicated by psychodynamic therapists, but also can occur between sessions in CBT, where patients are encouraged to expose themselves to situations that they may previously have avoided. It is of considerable interest that, early on, analysts have noticed that gradual, repeated exposure can reduce fear. This was pointed out by Fenichel in the 1940s, predating CBT exposure interventions.8
Aftab: What has been the response of your colleagues to your work on common principles of change? Do you see any signs of encouragement that things are beginning to change?
Goldfried: After thinking according to a particular school of thought for many years, therapists can find it difficult to think within a transtheoretical framework. Much of what they have read, and much of the training they have received, has been within a single conceptual framework, and existing habits of thought dictate how they conceptualize cases. Moreover, theoretical journals, professional networks, and conferences all serve as social and psychological contexts in which a therapist maintains his or her identity.
My sense is that the hope for the future lies with young professionals, consisting of graduate students and early career therapists and researchers. They are still struggling for their identity and forming their professional network, and I believe that we can help to change the zeitgeist within the field of psychotherapy by appealing to these individuals. This is precisely why I have decided to become involved in social media—I tweet @GoldfriedMarvin—as many of these early professionals are active there. The question is whether or not they want to continue the tradition of competing schools (causing the field of psychotherapy to remain a primitive science), or do they want to move it to a greater sense of maturity?
Aftab: In your vision of psychotherapy integration, what do you see as the endgame? The 2 possibilities that come to my mind are: 1) there is an eventual assimilation of various psychotherapy traditions into a single tradition, based on an integrative, transtheoretical framework, or 2) the various psychotherapy traditions will maintain their identities, but there will be increasing cross-communication and incorporation of techniques facilitated by the language of common principles of change. I suppose this question can also be rephrased as: are we or are we not condemned to pluralism?
Goldfried: I would hope we are not condemned to another century of competing schools, be they integrative or not. A mature science has an agreed-upon core as well as a cutting edge. I believe there exist some common principles/processes that cut across different schools of thought. The key question to address is: “On what can we agree?” That should be the focus of training, practice, and research. The ways of implementing these principles can vary, depending on the given case as hand.
Aftab: You have also commented on how psychotherapy research in recent decades has been more focused on outcomes and less on therapeutic processes. Can you tell us more about this?
Goldfried: Much of the direction of research in psychotherapy within the United States is determined by funding priorities set forth by the NIMH. In the 1980s, they moved in the direction of viewing psychotherapy within a medical context. Psychological problems were viewed as diagnoseable mental disorders, requiring research by clinical trials, in the same way that is done to certify medications. There are lots of problems with this, some of which I have commented on.6 Along with this shift to emphasize clinical trials came a decrease in funding for psychotherapy process research.
Aftab: One of themes you bring up in your work is that there is a disconnect between past and current bodies of knowledge, an absence of common language, and new approaches often end up rediscovering and reinventing past knowledge. What are some of the reasons why this is the case? In what ways does academic culture incentivize this?
Goldfried: There are various reasons why we forget what we have learned in the past. One is that we typically associate what is new with what is improved. Something that is old has some positive connotations, but also implies that it is worn out and less relevant. This may be true of the fashion world, but it is not true of science, which needs to build upon past findings.
In much the same way that drug companies often dictate what physicians do, book publishers have a comparable influence on therapy. In order for book publishers to stay in business, they need to publish books that contain new material. For example, introductory textbooks cannot contain too much old material in revisions, as they would be too unwieldy and expensive. Consequently, the past is often lost there. The existence of new information in books each year—all too often at the expense of past findings—is essential for their financial survival.
In addition, the professional the reward system depends on finding something that is new. Careers are made by making history, not knowing it. This often leads to the unfortunate practice of repackaging old concepts with new language, presenting it as new and improved. Unfortunately, many leaders in the field who do this are more interested in furthering their own careers than in furthering the field of psychotherapy.
Aftab: Thank you!
The opinions expressed in the interviews are those of the participants and do not necessarily reflect the opinions of Psychiatric TimesTM.
Dr Aftab 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 Psychiatric TimesTM Advisory Board. He can be reached at firstname.lastname@example.org or on twitter @awaisaftab.
Dr Aftab and Dr Goldfried have no relevant financial disclosures or conflicts of interest.
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1. Goldfried MR. Obtaining consensus in psychotherapy: What holds us back? Am Psychol. 2019;74(4):484-496.
2. Kendler KS. Toward a philosophical structure for psychiatry. Am J Psychiatry. 2005;162(3):433-40.
3. Goldfried MR. A professional journey through life. J Clin Psychol. 2015;71(11):1083-92.
4. Kramer PD. Ordinarily Well: The Case for Antidepressants. Farrar, Straus and Giroux; 2016.
5. Stricker G, Goldfried MR. The gap between science and practice: A conversation. Psychotherapy (Chic). 2019;56(1):149-155.
6. Goldfried MR, Wolfe BE. Psychotherapy practice and research. Repairing a strained alliance. Am Psychol. 1996;51(10):1007-16.
7. Goldfried MR. Toward the delineation of therapeutic change principles. Am Psychol. 1980;35(11):991-9.
8. Brunswick D, Fenichel O. Problems of Psychoanalytic Technique. Psychoanalytic Quarterly, 5th edition; 1941.