Confessions of a Developing Psychotherapist

I was educated in Client Centered/Rogerian psychotherapy. At that time, it was accepted that insight was king (whether by psychodynamic psychotherapies or the more easily accessible Client Centered psychotherapy). By the time I was applying for internship training, Client Centered therapy fell from “necessary and sufficient” to “necessary but not sufficient” (and with the popularity of brusque practitioners like Fritz Perls, Albert Ellis and Arnold Lazarus – it wasn’t clear that it was even necessary). For me, it felt like high school chemistry all over again. Mine was the last class to have to learn to use a slide rule.

This was the 70’s when bellbottoms, long hair, double knit suits and “eclecticism” were “in”. Eclectic was a useful label, as one could claim it with integrity. It was OK to declare overtly, “I do whatever the heck I feel like doing session to session.” At that time, Gestalt Therapy and Transactional Analysis were sexy modalities (really sexy with nude encounters at Esalan!). Dubbing oneself an Existential or Interpersonal therapist became a “fashion statement,” something clever and unusual. Psychoanalysts were in their own world. Behavior Therapy was reserved for relaxation training and those deemed to have inadequate capacity for insight, namely children and the mentally retarded.

It was a time to be open-minded. One intervention was not better than another. They were just different. Even practicing Primal Scream therapy was acceptable. Who were we to judge? Then there was this odd Rational Emotive Therapy (RET) of Dr. Albert Ellis. It appeared that RET was becoming the choice of shallow, crude nerds. Then Michenbaum and Beck came along and rescued a cognitive approach from an uncertain future.

In the 70s, the field of legitimate psychotherapeutic interventions was wide open. Yet this spring, when we asked attendees at a convention session to identify their primary treatment modality, some 80% chose Cognitive Behavioral Therapy. This shift cannot be accounted for by the charisma of Ellis, Michenbaum and Beck.

For also during this period, publications were appearing that were harshly critical of psychotherapy because it was lacking scientifically proven effectiveness. It followed that psychologists ought not to be practicing interventions that had no scientific support. But if practitioners engaged only those interventions that had demonstrated effectiveness in research, using research techniques and data then available, only one form of therapy would be practiced—drug therapy. Why? Simply because only the pharmaceutical companies were able to utilize the outcome methodologies available at that time to demonstrate the effectiveness of their products.

It is so fortunate for us that researchers like Drs. Barlow, Beutler, Linehan and Nathan did not abandon hope for psychotherapy effectiveness, but instead creatively honed their designs and methods to tease out the positive effects of certain psychotherapy treatments. Also fortunate for my family and me was that I didn’t abandon my practice while this research was being designed and conducted.

Practicing psychologists need research to support the enterprise of psychotherapy. But we prefer the research to simply assert; “Psychotherapy is effective.” We were not looking for a limited “formulary” of therapies that alone are proven effective. A case could be made that Dr. Marty Seligman was elected APA President on the strength of his association with the 1995 Consumer Reports article that concluded that psychotherapy is effective and further – more is better. Now that’s the kind of research we need. We would have elected him king if he ran for the position!

Psychotherapy research had (and has) a huge impact on psychotherapy practice – or at least on psychotherapist’s labels of their practices. Psychotherapy researchers had shined their spotlight most brightly on the efficacy of Cognitive Behavior Therapy and the impact was dramatic. By the time the “nose of the camel” of managed care organizations (MCO) protruded into our tent, the interviewers who determined who would be on their panels weren’t satisfied with “eclectic” as a psychologist’s primary modality without further definition. They didn’t appreciate “fashion statement” modalities. To report practicing “insight oriented” psychotherapy drew yawns and left the practitioner not likely to make the cut. What were the magic words that opened the gates to managed care panels? – Cognitive Behavior Therapy. One received extra credit if they also said they practiced “brief, symptom focused, goal-directed Cognitive Behavior Therapy.” Now I have psychiatrists referring patients for “CBT.” I have patients who present asking if I do “CBT.” Regarding treating certain diagnoses, some researchers and clinicians are stating “It’s almost malpractice to intervene with anything besides CBT.” So is CBT the treatment of choice for most disorders? Should we abandon interventions that we were taught by experienced, seasoned clinicians that research has not yet validated? Where does the best knowledge reside?

I took a sailing class from an 80-year-old “salty” sailor. Every so often he would tell us to ignore the book and follow his instructions. For instance, as soon as we were in open water, he asked us what we would do if he fell overboard. We smartly recited the “figure 8 man overboard” drill of which we had read. He answered, “OK but if it’s me that’s in the water, just come about, stop the boat and let me back on!” He went on to tell us that the directions in the books work, but his experience guided him to better or more efficient solutions. During the weekend, when he gave us options to the book, I considered them both and invariably chose his way. Practical experience gained from real life situations is valuable.

Over the years I have gravitated to treating anxiety disorders and have used material from Michenbaum, Beck, Mahoney, Barlow, Suinn and others. I have learned to adjust my interventions to fit the patient’s needs. For example, I carefully choose my words and my manner in first sessions to maximize hope for change and initiate the treatment process. I negotiate treatment goals with my patients in the first session or two. For some of these goals, I provide education, for some I provide direct advice, for some I provide opportunity for insight and/or catharsis. I have increased my attention to opportunities for change outside of therapy sessions. When something is not working, I back up, consider the obstacles and re-evaluate the plan. I do believe I am a considerably more effective therapist now than I was 20 years ago. As I consider what has improved the quality and efficiency of my practice, studying and honing techniques based on certain modalities and strategically shaping my style of interaction have both been important.

So again, ought we to discontinue psychotherapeutic interventions that have not been sufficiently supported empirically? Having already learned that it would have been wrong to abandon psychotherapy for lack of research proven effectiveness in the 60s and 70s, why would we now choose to abandon all other practices except ESTs? The research has illuminated only a small portion of the practice of psychotherapy. Research is not yet so clear on what doesn’t work. The studies have appropriately focused on the more readily examined and are moving to the more complex. Isn’t it a distinct possibility that once again ten years from now the list of interventions proven to be effective in clinical practice will grow? I am very willing to add effective interventions to my practice repertoire. But I am not ready to abandon other practices that are not yet validated by research. The data does not yet persuade me to so radically change my interventions.

Clinicians love most the research that says what we are already doing is great. We like the research that informs us of techniques proven to be effective that we can readily incorporate into our practices. We’re unhappy with guidelines that direct us to intervene in only certain prescribed ways, our unhappiness growing as the prescribed interventions vary from our own standard practices.

Publishing work on Empirically Supported Treatments is about developing Treatment Guidelines. They are coming now from a variety of sources and so far they’re not having significant impact on practices. As a result some psychologists report “So far so good.” We’re like the person at the 15th floor having fallen from a 20-story building. We haven’t felt the impact yet. What about when MCOs will pay only for those interventions consistent with their guidelines? How will we respond when a precocious patient tells us what work session #6 should include based on a treatment guideline she found on a website? Or worst of all, what will be the impact when psychologists find themselves in court or before the Board of Psychology defending themselves against accusations of straying from treatment guidelines?

We clinicians ought not to stick our heads in the sand and hope this all goes away. It is incumbent on us to stay abreast of the psychotherapy research, but more than that, to get involved in the research and the shaping of guidelines. Researchers are aware that they lack information about what is going on in clinician’s offices and what is happening for psychologists’ patients. We would all benefit from analysis of this real world data.

APA has already provided some opportunities for involvement in practice data collection. Division 42 is seeking 2,000 psychologists to participate in psychotherapy outcome and process research. The APA Practice Net is seeking psychologist volunteers who will agree to provide real time behavior sampling information. The Practice Research Network, spearheaded by Pennsylvania Psychological Association, is seeking a grant to link researchers and clinicians in gathering practice data for analysis.

It is only reasonable that we clinicians plan to be open to researcher’s requests for practicing psychologist volunteers to collect naturalistic data for the validation and improvement of our psychotherapeutic interventions. The future of the discipline of psychology is infinitely brighter as psychologist clinicians and researchers collaborate, bridging our differences to strengthen our profession.

(This material was first presented at the 2001 California Psychological Association annual convention)