Therapy

Psychotherapy in the 21st Century: What We Can Agree On

Five principles of change that might form a core of agreement on psychotherapy.

Posted Mar 03, 2021 | Reviewed by Gary Drevitch

This guest post was authored by Dr. Marvin R. Goldfried, Distinguished Professor of Psychology at Stony Brook University and co-founder of the Society for the Exploration of Psychotherapy Integration.

I once had a conversation with a physician in which I described the sad state of affairs within psychotherapy, indicating that there were numerous competing schools of thought, and that there was a long-standing gap between research and practice. His response was: “What did you expect?  Psychotherapy is an infant science.” I found this to be extraordinarily disturbing, especially since we have been doing this kind of work for over 100 years, and have accumulated a wealth of knowledge about therapy—both clinical and empirical. Unfortunately, however, this wealth of knowledge has not really translated into consensual and cumulative knowledge. This is because there is so much disagreement about the philosophical assumptions and theoretical constructs associated with different schools of thought. Even within a general school of thought, such as psychodynamic, there are numerous points of disagreement. There is also a massive proliferation of techniques that have been developed for many kinds of problems, and consensus is unlikely to be found there.  

I have been concerned with the disorganized nature of psychotherapy for many years. In the early 1980s, together with Paul Wachtel and others, I co-founded the Society for the Exploration of Psychotherapy Integration (SEPI). The primary goal of SEPI has been to allow for collegial communication among therapists having different schools of thought, and for creating a dialogue between researchers and practitioners. This has gone on for several decades, and has been successful in lowering the walls that separate the different factions within psychotherapy. 

This exploration has set the stage for us to potentially move to the next stage, namely the process of generating a foundational core of agreement. I have long argued that the proper level of analysis for consensus is principles of change. To illustrate this level, consider the following three quotes, made by theorists and therapists grounded in fundamentally different schools of thought.

In 1941, the psychoanalyst Otto Fenichel suggested a procedure for fear reduction. He wrote:

...when a person is afraid but experiences a situation in which what was feared occurs without any harm resulting, he will not immediately trust the outcome of his new experience; however, the second time he will have a little less fear, the third time still less (Fenichel, 1941, p. 83).

Albert Bandura, describing a cognitive-behavioral approach to fear reduction, wrote:

Extinction of avoidance behavior is achieved by repeated exposure to subjectively threatening stimuli under conditions designed to ensure that neither the avoidance responses nor the anticipated adverse consequences occur (Bandura, 1969, p. 414).

Finally, Polster and Polster, describing how an experiential/humanistic therapist deals with fear reduction, indicated that the client needs to be given:

...the opportunity for relevant practice in behaviors he may be avoiding. Through his own discoveries in trying out these behaviors, he will uncover aspects of himself which in their turn will generate further self-discovery (Polster & Polster, 1973, p. 252).

Despite differences in theoretical orientation and the specific clinical techniques that might be used, all seem to reflect a similar principle of change, namely helping the client to have a corrective experience that is achieved via successfully approaching that which has been avoided.

When points of agreement or consensus occur across orientations, I believe what we indeed have is a robust phenomenon, as the agreement emerges in spite of different theoretical biases. Given the focus at the level of principles, the following are what I would suggest to be some of the important transtheoretical evidence-based principles of change.

  1. Fostering the patient’s hope, positive expectations, and motivation to change.
  2. Facilitating the therapeutic alliance, involving a good bond and the agreement on goals and methods.
  3. Increasing patients’ awareness of why they are having difficulties.
  4. Encouraging corrective experiences, where risks are taken to improve functioning.
  5. Emphasizing ongoing reality testing, involving a synergy between risk-taking and increasing awareness.

The academic argument for these principles has recently been made in the American Psychologist (see here). The ways these principles of change may be used in clinical practice, and how they articulate with a transtheoretical approach to case formulation and treatment, is described in detail in a chapter by Eubanks and Goldfried (2019), which can be accessed here.

It is useful to summarize these principles by framing them in terms of the following sequence: When clients come to therapy, they are often in a state of unconscious incompetence, meaning that they know that certain aspects of their lives are not working, but they do not know why. By establishing a good working alliance and building trust, the therapist and client begin to build an awareness of what contributes to the problem, such that clients shift into conscious incompetence. This refers to the idea that they are still struggling, but they now understand why. Then the therapy progresses toward active change and skill-building, and if there are successes in change, clients reach a stage of conscious competence. That means they now know how they might be different in the world and achieve more adaptive outcomes. If, over time, this becomes automatic, they then achieve unconscious competence, meaning that they can maintain their new level of adaptive functioning without much conscious effort.

I would hope that regardless of one’s theoretical orientation or preference for techniques, psychotherapists of all stripes might be able to agree with this principled formulation. If so, we might really start to build the foundation of a science of psychotherapy that moves us forward in the next 100 years—but hopefully sooner—finally addressing and answering the question: On what can we agree?

Marv Goldfried
Source: Marv Goldfried

Marvin R. Goldfried, Ph.D. is Distinguished Professor of Psychology at Stony Brook University. He is the recipient of numerous awards from various psychological associations, and most recently received the APA/American Psychological Foundation Lifetime Achievement Award for the Application of Psychology. He is past president of the Society for Psychotherapy Research (SPR), the Society for the Explorations of Psychotherapy Integration (SEPI), the Society of Clinical Psychology, and the Psychotherapy Division of APA. He is founder of the journal In Session and author of numerous articles and books. Dr. Goldfried is cofounder of the SEPI, and founder of AFFIRM: Psychologists Affirming Their Lesbian, Gay, Bisexual, and Transgender Family.

References

Bandura, A. (1969). Principles of behavior modification. New York: Holt, Rinehart, & Winston.

Eubanks, C. E. & Goldfried, M. R.  (2019). Future directions in psychotherapy integration. In J. C. Norcross & M. R. Goldfried (Eds.). Handbook of psychotherapy integration (3rd ed.). New York: Oxford University Press.

Fenichel, O. (1941.). Problems of psychoanalytic technique. Albany, NY: Psychoanalytic Quarterly.

Goldfried, M. R. (2019). Obtaining consensus in psychotherapy: What holds us back? American

Psychologist, 74, 484-496.

Polster, E., & Polster, M. (1973). Gestalt therapy integrated. New York: Brunner/Mazel.