Weaving Together the Art and Science of Therapy

Why therapy is an art that should rest on a solid scientific foundation.

Posted Aug 30, 2019

Visual Generation/Shutterstock
Source: Visual Generation/Shutterstock

During the last 60 years, the practice of psychological therapy has moved increasingly away from unscientific methods towards evidence-based and empirically supported ones. Indeed, owing to the pioneering contributions of visionary psychologists and psychiatrists like Arnold Lazarus (who coined the term “behavior therapy” to replace traditional “psychotherapy”); Albert Ellis (who pioneered Rational Emotive Behavior Therapy as an alternative to Freudian psychoanalysis and Rogerian person-centered therapy); and Aaron Beck (who laid the groundwork for cognitive therapy), the science of psychology was finally merged with the practice of therapy.

Nevertheless, although clinicians now have an impressive array of scientifically validated techniques to draw from, psychological therapy remains as much an art as it is, ideally, a science. (I state “ideally” because despite the fact that there are proven treatments for a variety of conditions, many therapists still cling to antiquated methods like psychoanalysis and others that have no scientific backing like past-life regression or “energy” treatments.)

The science of therapy has its roots in the soil of the work that Arnold Lazarus and Joseph Wolpe did in Johannesburg, South Africa during the late 1950s. Wolpe and A. Lazarus took the lessons from conditioning research (e.g., Pavlov) and applied them to the practice of therapy. Thus, “systematic desensitization” (a scientifically based treatment for anxiety) was introduced into the clinical repertoire and the marriage of psychological research and clinical practice began.

Some 60 years later, we now have incontrovertible treatments of choice for several common problems that many people seek help for. For example, exposure therapy for most anxieties like OCD, panic and phobias; cognitive therapy and behavioral activation therapy for most depressive conditions; CBT-I for insomnia; mindfulness for many stress-related problems; and medical treatments for most psychoses and bipolar illnesses. Hence, in the current era, the science of psychological therapy clearly points to treatments of choice. Failing to use these approaches when there is unassailable and unequivocal data to support them as first-line interventions is, in my opinion, remiss if not outright negligent.

In essence, the science of therapy is the preferential use of empirically supported and evidence-based methods. That is, treatments of choice that have received experimental validation. While using scientifically verified interventions is important, it is just a part of doing good therapy because there are vital aspects of the process that do not easily lend themselves to scientific inquiry—namely, the art of therapy that has yet to be dismantled by research. Therefore, even when clinicians use evidence-based treatments, a great deal of artistry is usually required to produce optimum results.

In essence, the art of psychological therapy includes of the following factors:

1.  Developing a strong therapeutic relationship.

As Professor Arnold Lazarus stated, “The therapeutic relationship is the soil that enables the techniques to take root.” No matter how knowledgeable, experienced, or skilled a therapist is, without a solid relationship underpinning the therapy process, results are likely to be sub-optimal. Because just as there are scientifically validated treatments of choice, there are also relationships of choice that have yet to be established by research findings. Hence, knowing how to cultivate and strengthen the therapeutic alliance with each unique client involves a great deal of artistry since it’s a skill that cannot be easily taught or, as of yet, determined scientifically. In fact, referring a client to another therapist with whom they may be more compatible, and have a better fit, can be seen as an important therapeutic intervention.

2.  Knowing when to use a proven method or technique.

Even when a good relationship has been established, and a therapist is knowledgeable about treatments of choice, knowing when to introduce and use a specific treatment is highly individualistic and requires the therapist to possess another element of therapeutic artistry. If the method is implemented too soon, it might overwhelm the client. Too late, and precious time will have been lost and the client’s distress needlessly prolonged.

3.  Knowing how to best use a proven method or technique.

It is also important for a therapist to know how to best use a scientifically proven method. For instance, it is well established that ERP (exposure and response/ritual prevention) is by far the best treatment for most cases of OCD. But how it is implemented needs to be individualistically determined. With some people, a “decapitation strike” right at the top of their exposure hierarchy (i.e., the list of their anxiety triggers from least challenging to most challenging) can be successfully done. With others, a far more gradual ascent up their hierarchy is better. And for some, before doing even the least anxiety provoking ERP challenge, laying the groundwork with relaxation training and imaginal exposure is best.

This is related to the concept of “readiness for change.” Some people enter therapy ready to take on significant therapeutic assignments right out of the gate. Others need a long runway before they can reach takeoff speed⁠—and even then, some can undertake only mildly challenging tasks (or discussions). Hence, knowing just where a given person is on the readiness for change spectrum is another element of therapy that is more of an art than a science.

4.  Determining appropriate boundaries.

Knowing when and where to set healthy boundaries in a therapeutic relationship is also an aspect of therapy that the laboratory has yet to elucidate. This involves matters of therapist self disclosure (sharing some personal information with a client), between-session contact (with whom is it helpful to text or talk with between appointments?), accepting or giving gifts and cards, giving some extra time to someone during a session, and accepting invitations to special events (e.g., the local college graduation of a person who had been in treatment with a therapist for academic problems since 6th grade).

Similarly, knowing when to include other important people in the therapy is an important consideration. In other words, when to suggest that a spouse or other family member come into the process of an initially individual therapy, or when to have individual sessions within the context of a relationship or family therapy

In summary, the science of therapy rests on the foundation of evidence-based and empirically supported methods and techniques. These are the well established treatments of choice that are best used as first-line interventions. The art of psychological therapy is far more nuanced and individualistic. It involves factors like establishing a strong therapeutic relationship, referring to another provider if there is not a good fit, knowing when to use a method, how to best use it, and within what boundaries it should be used.

Remember: Think well, Act well, Feel well, Be well!

Copyright 2019 Clifford N. Lazarus, Ph.D. This post is for informational purposes only. it is not intended to be a substitute for help from a qualified health professional. The advertisements in this post do not necessarily reflect my opinions nor are they endorsed by me.