Chapter 1. From Trusting Therapies to Trusting Therapists
Publication: Trusting in Psychotherapy
As broached in the “Introduction,” we can think of trusting in psychotherapy as a professional practice, and we can think of trusting in the therapist. In this chapter, I begin with the practice with the aim of shifting the focus from the therapy to the therapist. Be forewarned that in psychotherapy, the practice can be virtually inextricable from the practitioner. Yet, if we are to succeed, we therapists as well as our patients must trust in the practice, and the field of psychotherapy is inordinately complex as well as rife with disputes about best practices. We therapists need to discover what in the seemingly open-ended field of psychotherapy will we trust. For me, this has been a decades-long quest. You will not find consensus. Ultimately, you need to trust yourself in choosing the methods you consider trustworthy.
Not so blissfully ignorant of my ignorance, I entered the practice of psychotherapy unknowingly more than 50 years ago, in a way I assume would never happen these days. I was a senior undergraduate destined for graduate school in clinical psychology when my adviser suggested that I get my feet wet by working with a client in the university Psychology Clinic. His idea was not entirely crazy, only moderately so. The fact that I had already taken some graduate classes mattered less than the form of the therapy. The client was hampered by a public speaking phobia that threatened his new job, and I could use a procedure that was highly structured: systematic desensitization.
As therapies go, desensitization was simple to conduct: teach progressive muscle relaxation and then guide the client through imagined speaking scenarios that are increasingly challenging, while ensuring that he or she remains relaxed throughout the imagined events. It was easy for the two of us to do, and it worked. But something else was developing in the background: As his phobia diminished, my client wanted increasingly to talk to me about problems in his life. Perhaps, opening with his phobia, he had entered into the process with an important but not particularly fraught concern. In wanting to talk, maybe he was beginning to trust me with more personal matters. I will never know because I was in over my head. As I recall, we referred him on for psychotherapy—not a bad outcome. Only after having forgotten it for decades did I appreciate how formative this first experience of psychotherapy was. What is the scientific procedure for talking to people about their life problems? How would I know? Could I learn?
Unknowingly, I had started my psychotherapy career as a specialist. I gradually developed into a generalist with some more specific areas of expertise—a decades-long career path that posed never-ending challenges to becoming reasonably trustworthy. When I use the term psychotherapy throughout this book, I have the generalist version in mind: therapists who work with patients presenting with a wide range of psychiatric disorders and personal problems. As I make plain in this chapter, however, the specialist-generalist distinction applies in varying degrees to a nearly unlimited variety of blends. For me, learning to blend was not easy, and, unlike systematic desensitization, generalist psychotherapy never came easy. I needed to figure out how to talk with people plagued by psychiatric illness about their extremely challenging problems in living—mostly, problems in close relationships. More specifically, how could I do this work with confidence and competence?
As knowledge goes, science gets high marks for trustworthiness, and I will take as much as I can manage to acquire. In addition to conducting psychotherapy, I devoted a great deal of time to educating patients. I needed to feel confident in what I was telling them. And, in addition to teaching at all levels, I was writing books. In this work, too, I wanted to feel confident in the soundness of what I was teaching and writing. I needed to trust myself. Scientific knowledge played a significant role in all this work, but, to go back to my beginnings: When I had to talk with patients about problems in their life, science was not enough. Where did that leave me?
Today, all therapists have a multitude of theories and hundreds of brands to choose from. With my first patient five decades ago, however, what I needed to learn was out of sync with the method of treatment that was on offer. Psychotherapy integration, a broad movement in the psychotherapy field that has developed over the past three decades, offers the best general guidance for navigating the thicket of therapy approaches and methods on offer over the entire course of a professional career. But the most substantial research on psychotherapy shows that interpersonal skill—which can be viewed broadly as the capacity to cultivate trusting relationships—plays the predominant role in the effectiveness of the treatment. That interpersonal skill is largely a matter of personal development that begins in infancy, although it can be refined in the course of professional training and practice over the course of a lifetime. The professional development of the therapist is a career-long process of mastering the craft.
When we move past specialized therapies to more generalist practice, we continue to need scientific knowledge, but we also need much broader knowledge, including skill in developing trusting relationships with persons who are loath to trust—for good reasons. To embrace a nontechnical term, I will refer to this as personal knowledge. In this broad domain of knowledge, I include knowledge of ethics, most of which we acquire from culture, which includes religious traditions for many people. Apart from religion, however, we have a magnificent scholarly literature on ethics in more than two millennia of philosophy, including a burgeoning contemporary literature on trust and trustworthiness that I rely on throughout this book.
I have filled this book with quotations. If you have room in your memory for only one, hold on to the first two sentences of Huston Smith’s (1992) book, Forgotten Truths: “In envisioning the way things are, there is no better place to begin than with modern science. Equally, there is no worse place to end” (p. 1). This insight was entirely absent from my academic training in psychology, and, as an undergraduate, I had no appreciation for its application to psychotherapy. Along with Smith, I am not opposed to science; I am all for it. My foe is scientism—the view that science is the sole pathway to knowledge or, as applied to psychotherapy, to competent practice. I argue that scientism, under the banner of evidence-based treatments, has led us down a path to putting too much emphasis on developing therapies and too little on developing therapists. With some irony, I make a science-based case for going beyond science to fully inform the practice of psychotherapy. Seeking balance, I advocate science-informed humanism (Allen 2016). Along with predominantly ordinary language, we need some technical language and poetic language to talk about psychotherapy—utterly personal as it must be.
For orientation to this complex chapter, I outline the steps of my argument in Table 1–1. In the rest of this chapter, I elucidate the argument, with some anchors in the scientific and ethical literature. We delve more deeply into trust in subsequent chapters; here I provide a bird’s-eye view of the scholarly justification for putting trust and trustworthiness in the foreground.
1. Over the course of a century, psychotherapists have developed hundreds of competing brands of therapy, tailored largely to treating specific psychiatric symptoms and disorders. |
2. Research demonstrating efficacy has played a large role in developing and legitimizing many of these brands. |
3. Researchers have had difficulty demonstrating that any one of these myriad treatment approaches is generally more effective than any other. |
4. Concomitantly, extensive research on common factors has shown that a good therapeutic relationship contributes more substantially to the effectiveness of the therapy than do the particular theory, methods, or techniques employed. |
5. A good patient-therapist relationship does not abrogate the need to provide some specific treatment for the patient’s problems, but the choice of treatment often will be disconcertingly wide open. |
6. Research shows that treatment outcomes are improved by going beyond symptoms and disorders to adapt therapies to patients’ personal characteristics (e.g., ethnic or religious background, sexual orientation). |
7. We should shift the balance of our efforts from developing therapies to developing therapists, that is, promoting therapists’ knowledge, skills, effectiveness, and—from the broadest perspective—their trustworthiness as practitioners. |
8. Short of narrowly specializing, therapists need to find ways of integrating theories and methods throughout their career. |
9. Without abandoning specialized therapies, we need to broaden our purview to helping patients with their problems in living, which constitute the broader social context in which their symptoms and disorders develop; to a large extent, these problems in living are embedded in problems in relationships. |
10. Addressing problems in living requires extensive personal knowledge beyond professional education, including ethical knowledge. Science-informed humanism provides a model for the knowledge base of psychotherapy. |
11. Thinking about becoming increasingly trustworthy as a therapist provides a useful overarching framework for mastering the craft of psychotherapy over the course of a career. |
Evidence-Based Practice
We compose much of our human life in the form of stories. In my first effort as a psychotherapist, I could treat a symptom, but I was not prepared to contend with a life story. My friend and colleague Tom Ellis, a cognitive-behavioral therapist, told me a story about a young therapist he was supervising. Exceptionally adept, she had mastered many evidence-based procedures, but she was flummoxed about which one to employ with a patient whose problems were complicated and severe—not so simple as treating a phobia with systematic desensitization. The therapist could not see the forest for the trees: too many symptoms to match with too many procedures for an uncooperative and distrusting patient. Tom’s suggestion: “How about starting by getting to know your patient?”
As I was writing this chapter, I talked with my daughter, Yvonne, about her work as a speech and language pathologist who specializes in treating children with autism spectrum disorder. I marveled at the sheer delight she takes in these children’s extraordinary quirkiness—they are masters of individuality. But they need a great deal of help in finding commonality with adults and their peers. There is science behind Yvonne’s work, along with plenty of technique, but she is not training these children to speak; she is striving to engage them in communication, which requires personal contact and recognition—an appreciation of individuality. In establishing contact, she is working on the ground floor of trust. Her work is not so different from mine; it is psychotherapeutic, not dominated by science but informed by it. She teaches the children to communicate by getting to know them and helping them get to know her and, more importantly, their peers—the function of speech.
Too Many Choices
Consider the number of brands of therapy now on the market. Of course, it depends on how you count, but the consensus would be in the hundreds (Wampold and Ulvenes 2019). Improbably, my colleague, Peter Fonagy (2020), counted more than 1,400. How did we get ourselves into this absurd situation? It reminds me of my first experience in a Texas-size liquor store where I had gone in search of some wine. I encountered aisle after aisle of wine racks, the likes of which I had never seen. I was overwhelmed and rushed out of the store with one bottle. It was cheap, and it was terrible. I hope this sort of thing does not happen to a patient who is looking for a therapist.
The abundance of acronyms heralds the real trouble. Two or four letters can be accepted (PE for prolonged exposure, EMDR for eye movement desensitization and reprocessing) but three letters are preferred: CBT (cognitive-behavioral therapy), DBT (dialectical behavior therapy), MBT (mentalization-based treatment), ACT (acceptance and commitment therapy), and so forth. But we can do better than that, combining types of therapy with the disorders for which they were developed, for example: PE for PTSD (prolonged exposure for posttraumatic stress disorder), ERP for OCD (exposure and response prevention for obsessive-compulsive disorder), and DBT for BPD (dialectical behavior therapy for borderline personality disorder).
I was pleased to discover a diagnosis for my malaise in the face of all these brands and acronyms: theoretical exhaustion (Norcross and Alexander 2019) exacerbated by antipathy toward empirical imperialism (Castonguay et al. 2019). Worn out with the spate of brands and protesting the narrow demands for experimental evidence, I declared myself a practitioner of plain old therapy (Allen 2013c). At least I was in step with my three-letter acronym.
What Constitutes Evidence?
Prominent in the quest for evidence were studies based on the gold standard medical model for drug (and vaccine) development: randomized controlled trials comparing the improvement of patients randomly assigned to a treatment group with those assigned to a control group (or horse race comparisons between different types of treatment). This gold standard research method was instrumental in establishing the effectiveness of specific therapies and the effectiveness of psychotherapy as a whole. But the gold standard also has become oppressive in its scientistic extension into the practice of therapy more generally. Drugs and vaccines, along with placebos, can be manufactured such that any one variant is identical to another.
To approximate this medical model (very roughly), therapies need to be highly structured such that they can be replicated from one patient to the next (and, ideally, from one treatment setting to another). For this purpose, researchers develop treatment manuals to structure the therapy, and they monitor therapists’ adherence to the manuals. Moreover, the manuals typically are tailored for the treatment of specific psychiatric disorders and symptoms (akin to my treating the patient with a public-speaking phobia with systematic desensitization). Although essential for research, requiring therapists to practice by the controlled trial standards can put them in straitjackets. Most patients do not come with neatly packaged disorders or symptoms, and therapists must be flexible in many ways. At the price of a scolding conscience, therapists could simply ignore researchers’ standards. The advent of managed care, however, has put economic pressure on therapists to practice treatments supported by research. It is utterly reasonable to restrict payment to demonstrably effective treatments. We will not get a large population to take a vaccine without convincing them that it is safe and will prevent infection and disease. But effective psychotherapy is a far more complex intervention that is jointly created in a trusting patient-therapist relationship.
One point bears emphasizing in conjunction with potentially confusing terminology: controlled trials have concentrated heavily on treatments developed for particular psychiatric disorders. I am not exaggerating the dominant role played by this approach to psychotherapy research: “we estimate that approximately 90% of federal research grants for psychotherapy goes to comparing and disseminating manualized treatments for specific mental disorders” (Norcross and Wampold 2019b, p. 336). Borrowing from the medical language, these experimentally validated treatments are regarded as having efficacy. The term empirically supported treatments was employed to identify treatments supported by controlled trials, which would (understandably) appeal to insurance companies.
The alternative term to efficacy, effectiveness, is far broader, applied to treatments supported by more naturalistic studies that demonstrate clinical improvement associated with a treatment. Helpfully removing the straitjackets of manualized treatments, the American Psychological Association (APA Presidential Task Force on Evidence-Based Practice 2006, p. 273) defined evidence-based practice as “the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences.” The task force noted this definition’s similarity to one proposed by the Institute of Medicine: “the integration of the best research evidence with clinical experience and patient values” (p. 273). These definitions not only go beyond research evidence to take into account the broader context of treatment but also respect the value of research methods beyond controlled trials: “A sizable body of scientific evidence drawn from a variety of research designs and methodologies attests to the effectiveness of psychological practices” (pp. 273–274)—psychotherapy not least.
For starters, if we can accept the need for evidence-based practice, we are freed from linking therapies to specific theories and diagnoses, consistent with transtheoretical and transdiagnostic approaches to treatment that I discuss in this chapter. We can incorporate clinical experience and judgment into the process. We can shift our attention from treating the illness to treating the person who is ill, welcoming the individuality of the patient—and the therapist—into the process. In so doing, we have not simplified the problem of conducting trustworthy therapy; we have complicated it. And the complexity poses enormous challenges for conscientious therapists who aspire to be trustworthy.
Happily, decades of controlled research on efficacy along with more naturalistic studies on effectiveness have shown that diverse methods of psychotherapy result in substantial improvement. Yet this reassuring evidence comes with a disconcerting qualification: with the abundant competition in the horse races, researchers have not found a winner of the triple crown but rather have found a far-reaching, broad equivalence in effectiveness of diverse approaches. This finding has drawn much-needed attention to the limitations of the unbridled development of competing brands developed to treat psychiatric symptoms and disorders.
I must head off misunderstanding at this juncture. I am not arguing that we should ignore psychiatric disorders; on the contrary, spending a career working with serious mental illness, I could not have understood my patients’ experience and struggles without a great deal of knowledge about psychiatric disorders, and no one should dispute the value of the wealth of knowledge that researchers and clinicians have accrued over more than a century (Roberts 2019). I am convinced that learning about psychiatric disorders—trauma-related disorders in particular—contributed substantially to my trustworthiness. As demanding as it is to acquire, knowledge of psychiatric disorders is not enough. We might begin there, but we should not end there. For an overview of factors beyond diagnosis to which psychotherapy is best adapted, see Table 1–2.
| Common factors | Individualizing therapy |
|---|---|
Empathy | Ethnicity and race |
Positive regard | Religion and spirituality |
Genuineness | Treatment preferences |
Emotional engagement | Sexual orientation and gender identity |
Therapeutic alliance | Readiness for change |
Repair of ruptures in the alliance | Reactance |
Internalizing-externalizing |
Common Factors and the Therapeutic Relationship
The idea that commonalities play a more important role in psychotherapy than specific methods long antedated the proliferation of psychotherapies. Barry Duncan (2010) reviewed this early history, featuring the prescient work of Saul Rosenzweig, who published the paper “Some Implicit Common Factors in Diverse Forms of Psychotherapy” in 1936. When he was a graduate student at Harvard, Rosenzweig created an elaborate panorama of psychotherapy depicting diverse forms of healing, from ancient to modern. His array of healers included a Hindu god, Jesus, priests in confessionals, medicine men, and Anton Mesmer (a progenitor of hypnosis) as well as Freud. Writing that “no form of psychotherapy is without cures to its credit” and that the “therapeutic result is not a reliable guide to the validity of the theory” (Duncan 2010, p. 9), Rosenzweig referred to the dodo bird’s pronouncement from Lewis Carroll’s Alice in Wonderland: “Everybody has won, and all must have prizes.” As Duncan put it, Rosenzweig’s provocative pronouncement became “a symbol of the raging controversy” (p. 8) between the advocates of common factors and the developers of specific treatments.
By and large, subsequent decades of psychotherapy research have reaffirmed Rosenzweig’s conclusions, with ever-increasing methodological sophistication encompassing hundreds of studies with many thousands of patients. But we must be aware of qualifications to the dodo bird verdict, the most important being the following: The research does not show that any type of therapy is as effective as any other. The verdict pertains to well-established treatments that are supported by research—a multitude, but a fraction of all the therapies that have been promoted.
As psychotherapy research progressed, Rosenzweig acquired plenty of company. As Duncan put it, “If Rosenzweig wrote the first notes of the call to the common factors, Johns Hopkins University’s Jerome Frank composed an entire symphony” (p. 6). As Frank (1961) put it in the first edition of Persuasion and Healing: “Much, if not all, of the effectiveness of different forms of psychotherapy may be due to those features that all have in common rather than to those that distinguish them from one another” (p. 104). Albeit 25 years later than Rosenzweig, Frank was writing before the extensive research supporting his view had been conducted. In a later edition coauthored with his daughter, Julia (Frank and Frank 1991), Frank identified one broad domain of specificity, namely, cognitive and behavioral approaches directed at “relieving anxieties that are linked to particular stimuli, situations, or persons” (p. 216) by means of repeated exposure to the feared situation (even in imagination, as occurs in systematic desensitization).
With common factors in mind, Frank articulated a common state of mind shared by psychotherapy patients: demoralization (Frank 1961; Frank and Frank 1991). Accordingly, restoring morale would be a common process by which diverse therapies achieve their effect. Frank’s broad view of psychotherapy is consistent with the central emphasis I give to hope as it relates to trust (see Chapter 3, “Trusting”). Frank proposed four features common to effective therapy (Frank and Frank 1991): an emotionally charged confiding relationship, a healing setting, a conceptual framework that plausibly explains the patient’s problems and procedures for resolving them, and a healing ritual or procedure in which both patient and therapist actively participate and which both believe will be a means of restoring the patient’s health. Keep a caveat in mind, however: common factors exert their influence across brands of therapy, but we have no reason to believe that all therapies depend on all the common factors and certainly not all at the same levels (Weinberger 1995). Common does not imply universal. Empathy might be more important for some patients; a convincing rationale or credible technique might matter more to others.
What Are the Common Factors?
The research literature on common factors is voluminous, and I take as canonical those reviewed in Norcross and Lambert’s (2019b) recent volume, Psychotherapy Relationships That Work. This volume, to which multiple research groups contributed, synthesized the work of the third Interdivisional American Psychological Association Task Force on Evidence-Based Relationships. Here is the editors’ summary of the spirit of their work: “Most practice guidelines . . . depict interchangeable providers performing treatment procedures. This stands in marked contrast to the clinician’s and client’s experience of psychotherapy as an intensely interpersonal and deeply emotional experience” (Norcross and Lambert 2019a, p. 7).
Here I will confine myself to enumerating a set of common factors documented in a wealth of research based on meta-analyses designed to reveal broad patterns based on large data sets. You might liken these meta-analyses to fruit salads. For example, empathy, a familiar common factor, has been researched in dozens of studies with thousands of patients, rated from different perspectives (e.g., observers or patients), using different measures of empathy along with different measures of treatment outcome, in diverse types of therapy conducted by a multitude of therapists in an array of practice settings. After scouring the literature and carefully screening the studies for quality, researchers aggregate all the data and arrive at a statistic that quantifies the strength of the relationship between empathy and treatment outcomes. In so doing, they transform the fruit salad into a smoothie.
Readers will not be surprised that the quality of the patient-therapist relationship contributes substantially to the effectiveness of the therapy, regardless of the specific method employed. Three therapist characteristics that Carl Rogers (1951) identified as essential for change in client-centered therapy have garnered substantial research support: empathy (Elliott et al. 2019); positive regard in the form of warmth, nonjudgmental acceptance, and validation (Farber et al. 2019); and genuineness, including openness and transparency (Kolden et al. 2019). More generally, emotional engagement on the part of the patient and the therapist (as contrasted with a detached, intellectual process) also relates to a positive outcome (Peluso and Freund 2019).
The therapeutic alliance, a key facet of the patient-therapist relationship, is the most extensively researched of all the common factors. Christoph Flückiger and colleagues’ (2019) review encompassed more than 300 studies employing more than 30 different measures and including more than 30,000 participants. As defined by the authors, the alliance is a multifaceted concept, and Edward Bordin’s conceptualization has been widely adopted: “a collaborative stance in therapy built on three components: agreement on the therapeutic goals, consensus on the tasks that make up the therapy, and a bond between the client and the therapist” (p. 26). Research on the alliance includes ratings by therapists, patients, and observers. The strength of the alliance is consistently related to treatment outcomes across types of therapy, measures, and raters (i.e., patient, therapist, or observer).
Therapists should take heed: For distrusting patients who struggle with serious problems in close relationships, developing a solid alliance will be challenging, and the strength of the alliance will vary across the treatment and even from session to session or within sessions (Allen et al. 1996; Horwitz et al. 1996). For such patients, as it is with trust, a stable alliance might better be viewed as an optimal outcome of therapy than a precondition for effective therapy. Accordingly, researchers have been studying the process of repairing ruptures in the alliance (Eubanks et al. 2019b), although the research is limited in extent. Research to date suggests that repairing ruptures improves the treatment outcome, and there is promising evidence that training therapists in repair of ruptures has a positive effect on the treatment. More generally, I believe that conflict-free, close relationships are less trustworthy than those in which both members have developed confidence that naturally occurring conflicts will be resolved. Conflict-free relationships have not been put to the test. Psychotherapy offers an opportunity to practice conflict resolution in an emotionally fraught context—with a helpful guide.
Given the focus of this book, you might wonder, is trust a common factor? I began this book noting what seemed to me a surprising neglect of trust in the psychotherapy literature. I considered the absence of trust among the canonical list of common factors to be one instance of this neglect. Having devoted much attention to the study of trust in the course of writing this book, I can see the logic in thinking of trust as a common factor. At least patients and therapists I have surveyed all consider it important. I discovered the inclusion of trust in a table of common factors, along with 31 others (Cuijpers et al. 2019), but trust is far from having garnered canonical status. I see no reason to believe that decades of research going forward will be devoted to making trust a part of the canon. I speculate that if we had several dozen studies with a few thousand patients in which patients’ trusting and therapists’ trustworthiness were measured, we would find that trust would fall in line with the canonical group: it would contribute significantly to the outcome, and it would overlap with the other factors. The research on trust also would suffer all the limitations of research on the other common factors.
Alternatively, we might consider trust and trustworthiness an overarching way of thinking about what we want to achieve in psychotherapy. For patients whose problems developed in the context of profound distrust, trust and trustworthiness could be the most valuable gains from psychotherapy. As I implied in the lead-up to this section, these common factors go into comprising a therapist’s trustworthiness: being empathic, affirming, and genuine; cultivating a therapeutic alliance; and working to repair ruptures. And there is far more to a therapist’s trustworthiness than what these common factors encompass—not least employing specific methods to address the patient’s problems and psychiatric disorders, including knowing when to refer to specialists (or, as in my early case, to generalists). Meanwhile, we have yet more ground to cover in developing a comprehensive research perspective on contributors to trustworthiness.
Should Common Factors Replace Specific Treatments?
The decades-long research on common factors has yielded hard-won knowledge, and therapists should be aware of it. Focusing entirely on theories and associated treatment methods and techniques overlooks the entire body of research findings. Compared with the relatively patchy evidence for the superiority of one brand of therapy compared with another, the evidence for the contribution of the patient-therapist relationship is powerful and extensive. In my view, this research on common factors casts a dark shadow over the effort that has gone into developing hundreds of brands of therapy, insofar as the training of therapists and their continuing professional development has greatly overemphasized theories, schools, brand names, and techniques to the neglect of developing therapeutic relationships. I think the pressure from science has led us to putting too much trust into theories, brands, and techniques.
Rogers (1992) proposed that a good relationship is the necessary and sufficient condition for effective psychotherapy. This is a tempting conclusion, given the broad comparability in effectiveness among brands coupled with extensive evidence indicating that the quality of the relationship contributes more to the effectiveness of the treatment than the brand of therapy applied. However, relatively small as the contribution of specific treatment methods to outcome may be, we generalists must keep in mind that specialized treatments can have an advantage for targeted symptoms (Marcus et al. 2014).
I have experience with such specialization, working closely with my colleague Tom Ellis, who has specialized in understanding and treating suicidal patients throughout his career. We implemented David Jobes’s (2006) approach, collaborative assessment of management of suicidality, which is not a manualized therapy but rather incorporates into psychotherapy a systematic assessment of factors that are known to contribute to suicidality, such as psychological pain, self-hate, and hopelessness. The approach builds a therapeutic alliance in relation to understanding and resolving problems associated with these contributing factors along with assessing weekly progress on rating scales throughout the course of the therapy. I found this approach appealing because it focuses the therapy on key life problems and can be adapted to the therapist’s preferred approach (Tom’s being cognitive-behavioral, mine psychodynamic). We randomly assigned patients throughout the hospital to therapists who were practicing this suicide-focused approach and to those who were conducting the therapy as usual. We were not optimistic about finding significant differences between these two therapy groups because the twice-weekly therapy sessions were immersed in a plethora of inpatient interventions that we would expect to have an overwhelming influence. Nonetheless, we found significantly greater decreases in suicidality over the course of hospitalization in the suicide-focused therapy group than in the treatment-as-usual group (Ellis et al. 2012). This finding is consistent with potential advantages of specialized methods for target symptoms—suicidality being a particularly crucial target.
More broadly, Bruce Wampold, one of the foremost proponents of common factors, argued persuasively that the battle between specific methods and common factors cannot be won (Wampold and Imel 2015). Consider: How could you have a therapeutic alliance without a treatment approach as the basis for an alliance? Could you ignore the patient’s problems and symptoms while striving merely to create a therapeutic relationship? Therapeutic for what? Could you ignore the patient’s psychiatric disorder—anxiety, depression, psychosis, substance abuse, posttraumatic stress? Not if you work with patients whose functioning is compromised by these disorders. In my experience, all these problems, symptoms, and disorders are typically entangled in relationship problems, and these relationship problems often have developed over much of the patient’s lifetime. Accordingly, the common (relational) therapeutic factors are profoundly important—and therapeutic indeed. But the relational problems must be addressed specifically, by some means or other. In short, there is no treatment without a therapeutic relationship and no therapeutic relationship without a treatment.
Individualizing Psychotherapy
The focus on common factors and therapeutic relationships has taken us one step beyond the more ubiquitous development of methods for treating disorders. But we must take another step. Sir William Osler, the “father of modern medicine,” famously wrote in 1906, “It is much more important to know what sort of a patient has a disease than what sort of disease a patient has” (quoted by Norcross and Wampold 2019a, p. 2). Accordingly, researchers have been studying transdiagnostic characteristics of patients to which therapies should be adapted, and they have employed meta-analyses showing that such adaptations improve the effectiveness of treatment (Norcross and Wampold 2019a). My cursory review makes no attempt to summarize these huge domains of pertinent knowledge but aims merely to draw attention to their pertinence to therapists’ trustworthiness.
Cultural Adaptations
Patient-therapist differences in cultural, racial, and ethnic background are liable to pose significant challenges for trusting, and these differences are one of many contexts in which the trustworthiness of the therapist is likely to be on the line. In the context of such differences, patients can have concerns about stereotyping and prejudice along with doubts about the therapist’s capacity to understand them. Cultural diversity training is a common requirement in continuing education for professional licensing, but it only scratches the surface and risks perpetuating stereotypes.
Research literature provides some orientation to the challenges, and it falls under two broad categories: cultural adaptations of therapies and cultural competence of therapists (Soto et al. 2019). Cultural adaptations include matching patients and therapists for ethnic or racial backgrounds, employing the patient’s preferred language, explicitly addressing patients’ cultural values, using appropriate rituals and metaphors, and consulting with family members as part of individual therapy. Research has shown a modest relation between the number of such adaptations employed and the treatment outcome.
Perhaps more directly related to trustworthiness is the therapist’s cultural competence, which includes cultural awareness and knowledge along with skills in engaging diverse patients in treatment while adapting the therapy to their preferences and needs. Patients’ perceptions of therapists’ cultural competence and cultural humility contribute to the therapeutic alliance and treatment outcome (Soto et al. 2019). As Hayes and colleagues (2017) put it, most important is “a humble, respectful, and open approach to addressing culture in therapy” (p. 159). Furthermore, the research evidence suggests that “therapists with cultural expertise acknowledge when they do not have specific knowledge about a culture and have a high tolerance for not knowing” in the context of appreciating the impact of cultural socialization on mental health (p. 163). As with all else, trustworthiness entails learning about patients from the patients themselves. But we need a balance: patients can assist in educating therapists about their culture, but therapists should not put undue burden for their own education on their patients.
Religion and spirituality are prominent aspects of culture that require attention in psychotherapy along with an attitude of cultural humility. My own history is embarrassing, and a confession might be instructive. Several years ago, I worked in long-term therapy with a pastor whose wife’s severe psychiatric disorder was a source of his chronic stress and depression. He was devoutly religious; as he doubtlessly inferred, I am not religious. I did not explore the role of his faith in his emotional distress, nor did he bring it up. I think I was apprehensive that our religious differences would lead to a rift in our relationship. In hindsight, I now believe that my failure to address this difference created an unspoken rift that we could have overcome with a more mature attitude of cultural humility on my part. His graciousness made a major contribution to our good relationship; when we ended the therapy, he let me know that he believed that God was working through me. That was high praise indeed. I have not become religious, but I have become far more open in the decades since. I now appreciate that my constriction was a significant limitation in my practice of therapy—likely compromising my trustworthiness in ways I will never know.
Kenneth Pargament and colleagues (2013) made a strong case for psychotherapists to develop attitudes and competence conducive to addressing religion and spirituality in their work when indicated by patients’ preferences and needs. As has long been known, spirituality and religious participation are associated strongly with mental and physical health. Less well known is the extent of ill health—mental and physical—associated with what Pargament calls spiritual struggles (Exline 2013; Pargament 2007) in three domains: interpersonal (e.g., conflicts with families, friends, and congregations), intrapersonal (e.g., doubt about doctrines and beliefs as well as conflicts about religious prohibitions), and divine (e.g., feelings of alienation and anger toward God or being at war with demonic forces). Also profoundly damaging is spiritual trauma associated with sexual abuse by priests and other members of the clergy (Allen 2007; Doyle 2003), which evokes extreme distrust in God or a “higher power,” as well as distrust in religious institutions and potentially in authority more generally.
We therapists need not specialize in religious interventions or even be religious to provide spiritually conscious care; we need cultural humility in the form of curiosity and respect for differences along with willingness to plunge into unfamiliar territory. Yet some therapies have been designed to adapt to patients’ religious and spiritual needs in the context of treating psychiatric disorders (Hook et al. 2019). Attesting to specificity, controlled studies indicate that integrating religion and spirituality into treatment for interested patients yields similar levels of improvement for psychological symptoms but greater gains in spiritual well-being.
Given the ever-shifting cultural sands, working effectively with sexual orientation and gender identity can be challenging for psychotherapists. Stephanie Budge (Budge and Moradi 2019) and Bonnie Moradi (Moradi and Budge 2019) scoured the research literature for studies on the effectiveness of LGBTQ+ affirmative therapies and came up with one major empirical finding: there are no such studies. Accordingly, they reviewed the substantive clinical literature and concluded by reiterating the recurring theme: “Clients should be approached with humility and curiosity and understood with their full humanity, salient experiences, and identities. This humble approach should be paired with therapists’ understanding of the sociopolitical climate for transgender individuals” (Budge and Moradi 2019, p. 152, emphasis added).
Individual differences in race, ethnicity, religion, gender identity, and sexuality commonly have been fraught with tension and conflict, and this conflict is now in full view in our currently superheated political climate. Ideally, the compassion, acceptance, and respect that psychotherapy optimally offers can provide some refuge and a safe space. In this context, however, thinking that becoming trustworthy in conducting psychotherapy is easy or taking trustworthiness for granted—especially in our current political climate—is a failing in cultural humility.
Treatment Preferences and Readiness for Change
There are many pathways to a therapist’s office, and the opportunity for patients to express their treatment preferences and have them honored will vary. If patients are not offered an opportunity to express preferences, they should make them known. For this purpose, Mick Cooper and John Norcross developed a brief inventory that can be administered to patients prior to assignment to a therapist (Cooper and Norcross 2016). The questionnaire includes a set of rating scales to assess preferences for therapist directiveness, emotional intensity, focus on the patient-therapist relationship, and warm support versus challenge. The instrument also contains open-ended questions to gauge preferences regarding personal characteristics of the therapist, type and frequency of therapy, inclusion of medication, and so forth. Research shows that honoring patients’ preferences is associated with better treatment outcomes; moreover, failing to honor preferences nearly doubles the rate of dropout (Swift et al. 2019).
Patients come to therapy suffering and seeking help; naturally, they will work hard and cooperate with therapists in seeking relief. Perhaps this scenario plays out often enough in symptom-oriented treatments. Psychotherapy with patients who struggle with problems in relationships—including distrust—does not go so smoothly. As has been a main concern of psychoanalysis since its inception, patients who are ill may resist the therapist’s efforts and even actively fight change. As a therapist, taking a readily developed therapeutic alliance for granted is about as reasonable as taking a trusting attitude and your own trustworthiness for granted.
In contrast to the psychoanalytic concept of resistance, the stages-of-change model was developed to apply to all theoretical approaches and methods of therapy, although it has played an especially prominent role in the treatment of addictions and problematic behaviors more generally (Krebs et al. 2019; Prochaska and DiClemente 2019). Five stages have been distinguished. In the precontemplation stage, the patient has no intention of changing and might not even be aware of the problem (e.g., alcohol abuse). Often, persons who are close to the patient (e.g., family members or employers) are keenly aware of the problem, and those who seek treatment are liable to feel coerced (i.e., by an intervention). In the contemplation stage, patients are aware of the problem and their conflicts about changing, but they remain uncommitted to taking action. Patients may spend much time in psychotherapy in the precontemplation and contemplation stages; increasing self-awareness and addressing conflicts often calls for an insight-oriented approach in the context of a strong therapeutic relationship. In the preparation stage, the patient is committed to changing behavior in the near future and beginning to take small steps in that direction. The action stage entails modifying behavior as well as changing the environment or situation (e.g., getting rid of liquor or a stash of pills kept for suicide or terminating an abusive relationship). The maintenance stage revolves around consolidating changes and preventing relapse. It is not uncommon (albeit discouraging) for patients to cycle through these stages in the context of relapses. Extensive research shows that adapting the therapeutic approach to the patient’s stage of change reduces dropouts and improves outcomes (Krebs et al. 2019).
Personality Traits
In contrast to resistance and readiness for change, reactance has been identified as an oppositional or avoidant response to persuasion or pressure to change. Reactance might be perceived (as in a child) to be willfulness or obstreperousness, but it is better understood as being rooted in a fear of losing one’s autonomy or independence. Accordingly, reactance lies not in the patient but rather in the therapeutic relationship: reactance is a response to directiveness or, in the extreme, to controlling behavior. Vicious circles can develop quickly as efforts to control abet reactance, which escalates efforts to control, and so on. Accordingly, less directive approaches that give the patient space and emphasize autonomy are best suited to patients who are relatively high in reactance. In contrast, patients who are lower in reactance may benefit from more directiveness. Although the research base is relatively small, substantially better outcomes are associated with matching therapist directiveness to patient reactance (Edwards et al. 2019).
The personality dimension ranging from externalizing to internalizing also has implications for adapting the style of the therapy to the characteristics of the patient. Persons prone to externalizing tend to blame their problems or distress on the environment—typically, other persons. In contrast, persons prone to internalizing tend to blame their problems and distress on themselves. Externalizers are more prone to action (and anger) and internalizers to introspection (and guilt feelings); correspondingly, externalizers are more extroverted and internalizers more introverted. Although the studies are few, research indicates that externalizers respond better to symptom-oriented approaches that emphasize action, whereas internalizers respond better to insight-oriented approaches that promote introspection (Beutler et al. 2019).
Factors Beyond Psychotherapy That Influence Outcomes
We also must keep in mind that psychotherapy does not take place in a vacuum. Norcross and Lambert (2019a) attribute 40% of the change that takes place to factors outside the therapy, prominently including social support and life events. They also include self-change, and, as Amanda Edwards-Stewart and John Norcross point out, we therapists should not lose sight of the fact that “[s]elf-help, not psychotherapy, is the de facto mental health system” (Edwards-Stewart and Norcross 2019, p. 358). The authors noted that 5,000 self-help books are published each year, and there are 25,000 websites devoted to mental health, along with thousands of apps. They cautioned that “less than 5% of commercial self-help books and 1% of web and mobile tools possess any research evidence on their effectiveness or safety” (p. 365). Of course, patients can use self-help resources in conjunction with psychotherapy, and therapists can encourage their use as well as assist with it.
Inside the therapy, we should keep in mind that the patient’s characteristics play a far greater role than the therapist’s contribution, the therapy relationship, and the treatment method. As in general medicine, the chronicity and severity of the illness strongly influence the outcome. In the field of psychotherapy, patients with severe illnesses respond positively to treatment, but the treatment often must be lengthy and intensive. With some irony, Arthur Bohart and Karen Tallman referred to clients as the “neglected common factor” in psychotherapy (Bohart and Tallman 2010, p. 83) and pointed out that “the client and factors in the client’s life account for more variance in the therapeutic outcome than any other factor” (p. 84). Furthermore, they emphasized that the client does the work of changing, with help from the therapist.
What Happened to the Therapist?
Decades ago, I went out for my morning jog and crossed paths with Irv Rosen, the director of psychotherapy at the Menninger Clinic. We circled around the park together for a while. I brought up my fraught experience in a research team conducting an intensive study of psychotherapy with patients diagnosed with borderline personality disorder. We were investigating what kinds of interventions would increase (or decrease) the therapeutic alliance within therapy sessions (Horwitz et al. 1996). Some of us had tape-recorded our sessions, which were then transcribed and evaluated by the research group. The group members included a number of psychoanalysts who were senior to me, including my boss, Len Horwitz, the leader of the project and director of psychology. To say the least, this close scrutiny was often painful, as I lamented with Irv while we jogged around the park. The psychotherapy I was conducting was hardly going smoothly (which is par for the course for patients with severe borderline personality disorder). Irv’s response: “Now you know why therapists don’t do psychotherapy research!” This comment should be restricted to therapists’ reluctance to doing research on themselves. We are less apprehensive about doing research on our treatment methods. But we cannot exclude ourselves from the research if we want to improve our effectiveness.
Research on treatment methods pertains to trust in an impersonal sense: to what extent can the patient (and therapist) trust that the treatment method will be effective? Starting from the premise that “there is no single right way to conduct psychotherapy” (p. 303), Paul Wachtel (2008) acknowledged that his therapeutic practice “reflects not just my theory but who I am as a person. This is my way of working with people. It bears a significant relationship to what my theory is, but it is partly simply me” (pp. 266–267, emphasis in original). Only in the latter part of my career did I fully appreciate the truth and import of Wachtel’s stance. Consistent with his view, research on the therapist makes it personal: To what extent can the patient trust me? Am I competent? Caring? Able to help? Trustworthy in all these ways? Not necessarily and, under the best of circumstances, not continuously.
To cut to the chase, as editors Louis Castonguay and Clara Hill put it in the preface to their book on therapist effects, “Not all therapists are equal . . . some therapists are better than others at helping clients . . . some therapists are substantially less effective, and even more harmful, than the majority of practitioners” (Castonguay and Hill 2017b, p. xiii). Wampold and colleagues (Wampold and Imel 2015; Wampold et al. 2017) conducted extensive analyses of the research literature and concluded that the effect of the person of the therapist “actually is quite large, much larger, for example, than the differences between treatments” (Wampold et al. 2017, p. 40, emphasis added). Michael Barkham and colleagues (2017) made the same point more cautiously: “it appears to be at least, or maybe more, important who clients see rather than what specific therapy is offered” (p. 26, emphasis added).
Now I am reiterating the point that therapy researchers largely have been barking up the wrong tree in focusing so much attention on brand comparisons. That line of research, in effect, treats therapists as interchangeable with one another. Differences among therapists are canceled out in evaluating the effectiveness of the specific treatment. From a research perspective, like placebo effects in drug trials based on positive expectations, the effect of individual therapists is a nuisance—noise or error variance. In psychotherapy, however, expectations about the effectiveness of the treatment play an important part in the treatment outcome, and these expectations are influenced by the therapist. When we ignore the effect of the individual therapist, we are erroneously attributing the effectiveness—or lack thereof—to the specific treatment. As Barkham and colleagues (2017) commented, favoring research on treatments to the neglect of therapists “is surprising given that they are the most valuable and costly component in the delivery of psychological therapies” (p. 13). But we are not completely in the dark, not least because we now know where we need to shine the light. Research has been illuminating; several notable findings are summarized in Table 1–3.
A large proportion of therapists are effective (Barkham et al. 2017). |
Patients of the top 15%–20% of therapists have twice the recovery rate of the bottom 15%–20% (Barkham et al. 2017). |
For severely disturbed patients, the influence of the therapist is four times greater than for the least disturbed patients (Barkham et al. 2017). |
Therapists tend to overestimate their effectiveness (Boswell et al. 2017). |
Therapists are poor at detecting patients’ deterioration (Lambert et al. 2019). |
We need to keep in mind the broader context of the dodo bird verdict: Psychotherapy in general is highly effective. But no patient receives psychotherapy in general. Barkham and colleagues (2017) concluded that, compared with the middle 60%–70% of therapists, 15%–20% of therapists have better outcomes and 15%–20% have worse outcomes. Accordingly, “the middle two thirds of therapists cannot be confidently and reliably distinguished from each other with regards to the amount of change they facilitate in their clients” (p. 26). Barkham and colleagues find it reassuring that a large proportion of therapists are doing a good job. Less reassuring, however, is the fact that “the average recovery rate for the more effective therapists is almost twice that of the less effective group” (pp. 22–23); that is a big difference. Also worrying is the finding that “therapists tend to overestimate their own general effectiveness with clients, as well as their effectiveness relative to other therapists” (Boswell et al. 2017). More specifically, Miller and colleagues (2017) report: “Studies show that the least effective believe that they are as good as the most effective and that average clinicians overestimate their outcomes on the order of 65%” (p. 24). Psychotherapists are not alone; research shows that physicians also overestimate their effectiveness (Taylor and Neimeyer 2017).
The broad findings regarding therapist effects need to be qualified. Most important, differences among therapists come into play most strongly in the treatment of patients whose problems and disorders are more severe. Barkham and colleagues (2017) found that the influence of the therapist is four times greater with patients who are severely disturbed than with those who are least disturbed. Accordingly, they concluded that “if clients present with a low level of severity, it might be that the required level of clinical skill is more generic to most practitioners” (p. 25). As severity of disturbance increases, so does the influence of the therapist as an individual.
I have been focusing in this book on psychotherapy as conducted by generalists, who treat patients with diverse problems and disorders (akin to internists and family practitioners in general medicine). As Michael Constantino and colleagues (2017) reviewed, the magnitude of therapist effects (individual differences) differs for different psychiatric disorders and problems. For example, therapist effects are more prominent for patients with depression, substance abuse, or quality of life than for those with psychosis or mania (insofar as psychosis or mania will be more responsive to medication, which could facilitate psychotherapy). In addition, a given therapist is likely to be more effective in treating some problems or disorders than others (e.g., more effective with depression than substance abuse or vice versa). Moreover, therapists differ from one another in the level of consistency in effectiveness. Constantino et al. (2017) found that “Many therapists demonstrated effectiveness over multiple domains, yet no therapists demonstrated reliable effectiveness across all domains. A small but notable 4% of therapists failed to demonstrate positive outcomes on any domain” (p. 56). Finally, therapist effects are more prominent in routine practice than they are in randomized controlled trials, which require adherence to treatment manuals, wherein therapist differences are deliberately minimized (Wampold and Imel 2015). In those trials, ideally, therapists could be trained to be interchangeable. Ironically, therapists vary substantially in their adherence to the treatment manuals in those trials (Constantino et al. 2017).
I credit the dodo bird verdict for generating a shift in our perspective on psychotherapy insofar as we are witnessing a retreat from the generation of countless brands of treatment to broadening our purview of myriad contributors to treatment outcomes and their relative magnitude. Over the past few decades, clinician-researchers have developed an alternative way of thinking about the field under the broad rubric of psychotherapy integration. This approach does not simplify the life of the therapist; it complicates it. But it provides a platform for new ways of looking at the psychotherapy literature and going beyond this literature to appreciate the far wider field of knowledge and experience that contribute to the psychotherapist’s personal and professional development.
Psychotherapy Integration
How did we wind up with hundreds of competing brands? Pointing to competitiveness and professional rivalry, Norcross and Alexander (2019) proposed that “professional reputations are made by emphasizing the new and different, not the basic and similar . . . . [T]here is far too much emphasis on the ownership of ideas” (p. 20). Thus, we have brands, acronyms, jargon, and buzzwords in abundance. But competition and self-promotion are not the whole story. Often, therapists who have been brought up early in their career under one tradition find themselves hamstrung by it and realize that they must be more flexible; they must learn, discover—and sometimes create—something new. I learned in my very first attempt at psychotherapy that I would need to learn something very different. It took me about a decade to get started.
Given that therapists are inundated with an array of brands that they could never learn about—much less master—psychotherapy integration is the only pathway forward that makes sense to me. A concerted effort to overcome professional rivalries and boundaries was launched in 1983 by the formation of the Society for the Exploration of Psychotherapy Integration by therapists united in part in being critical of the wholesale adoption of manualized, empirically supported therapies, which failed to respect the flexibility needed in typical clinical practice. Different approaches to integration include focus on common factors as discussed earlier in this chapter as well as efforts to integrate theories and techniques (Norcross and Alexander 2019). Most appealing to me is the strategy of assimilative integration that typically starts with the therapist acquiring a solid grounding in one psychotherapy system and then gradually incorporating theories and combining techniques from other systems. I am partial to the assimilative integration version because it focuses our attention on the professional development of the therapist. More broadly, I am partial to the integrative approach because it is the best framework to structure the developmental challenges that all therapists will face—not only in the early years but also throughout their career. Therapists who stand still will be out of step.
I find Wampold’s contextual model (Wampold and Imel 2015) especially instructive. As I noted earlier in this chapter, Wampold asserted that the battle between common factors and specific ingredients rests on a false dichotomy: “specific ingredients and common factors are not mutually exclusive but work together to make psychotherapy effective” (Wampold and Ulvenes 2019, p. 69). In the contextual model, psychotherapy begins with the formation of an initial bond in which trust plays a prominent role in conjunction with the therapist’s understanding and expertise. The fate of the therapy can hinge on this initial bond: “most patients who drop out of therapy prematurely do so after the first session or two” (Wampold and Ulvenes 2019, pp. 72–73). Wampold distinguishes three pathways to change: a relationship based on realistic perceptions of the therapist as authentic, warm, empathic, and caring; the creation of positive expectations for change by means of an explanation of the treatment that is credible to the patient; and specific ingredients that include goals and tasks, therapeutic actions, and the patient’s actions that decrease illness and promote health.
I believe that Wampold’s way of understanding the relation of the common (relationship) factors to the specific (treatment) factors applies widely to psychotherapy. That is, the relationship “serves as the foundation for other therapeutic processes and actions” (Wampold and Ulvenes 2019, p. 73), the “vehicle for delivering the specific ingredients” (p. 71), and “sets the stage for the client to collaborate” (p. 75). This reasoning is consistent with viewing the therapeutic alliance as valuable insofar as it enables the work of therapy. In effect, a positive relationship and alliance are preconditions for the therapeutic process. Yet this means-end model can be highly misleading; it applies best to short-term therapies where cooperation is easily established. Consider patients whose capacity for trusting relationships has been profoundly impaired, for example, those with a history of chronic and severe trauma in attachment relationships. For such patients, the cultivation of trust with an intimate bond is not the foundation for therapy or vehicle of therapy; it is the work of therapy and the ideal outcome of therapy. Moreover, the therapy will be fully effective only to the extent that the improving quality of the therapeutic relationship generalizes to other relationships beyond the therapy. Furthermore, if profoundly troubled relationships are the fundamental problem that therapy must address—as is often the case for severely impaired patients with multiple psychiatric disorders—the specific ingredients will be the way the patient and therapist work together to create a healing relationship and generalize it to other relationships.
Wampold’s treatment model is consistent with myriad specific treatment methods as long as the broad components he has identified obtain in the treatment. I find irony in the integrative approach. It is intended to transcend differences, but there are many ways to integrate: a decade after it was created, “psychotherapy integration began to differentiate more clearly into separate paths or subtypes” (Goldfried et al. 2019, p. 44). Different approaches to integration now are being compared for effectiveness in research (Boswell et al. 2019), raising the question “Will more therapists begin to identify as integrative, and will integration become another entry in the theoretical orientation horse race?” (Eubanks et al. 2019a, p. 482). Boswell and colleagues (2019) referred to a “potential blizzard of integrations” and pointed out that “there is a danger that we are recapitulating the very problem integrative therapies were, at least in part, intended to address” (p. 422).
The psychotherapy integration approach will alter neither ambitious competitiveness nor the creative desire to find better ways of thinking and working. I think assimilative integration implies a developmental course for psychotherapists that is the best path to becoming trustworthy over the course of a career. Many will start the journey from a relatively pure form therapy base; others will begin with an orientation to psychotherapy integration (Norcross and Finnerty 2019). Regardless of your starting point (which could be from within the integrative movement), assimilative integration is the natural alternative to developmental stagnation. Given individual differences among therapists and patients, there will be innumerable developmental pathways. But I think the professional literature I have sketched is only one domain of a far greater territory. We have much more knowledge to integrate than the scientific literature on psychotherapy and psychopathology.
Personal Knowledge
William James (1890/1950), a physician and foremost American philosopher, wrote the two-volume founding textbook of psychology. I admire James especially for his broadmindedness, as captured by one of his biographers, Ralph Barton Perry (1996): For James, “psychology meant seeing man in the round—as he presents himself to the physician, the biologist, the traveler, the artist, or the novelist. Hence he was willing to learn about man from any source” (p. 193, emphasis added), as we psychotherapists should be.
When I first came across philosopher Michael Polanyi’s (1962, 1966) seemingly mundane concept of personal knowledge, I found it to be illuminating in relation to my concerns about the intrusion of scientism into the conduct of psychotherapy. Personal knowledge is individual, residing in individual minds. It is the sum total of what you know—not what resides in libraries or on the internet. Personal knowledge puts the knower in the knowledge, highlighting “the personal contribution by which the knower shapes his own knowledge” (Polanyi 1959/2014, p. 13). Keep in mind, as James articulated it, that knowledge of persons is the realm that concerns us. We begin acquiring all this personal knowledge in childhood and continue to do so throughout life; at best, our professional knowledge will enhance it, not replace it.
Thankfully, we professionals are hardly unique in being able to help people with psychological problems; we are newcomers to that ancient endeavor, which has always rested on personal knowledge. I worked with a patient who called me occasionally for many years after we terminated psychotherapy. One time she called me in a crisis; it was late in the evening, and I was unavailable. I talked with her the next morning, by which time she was as calm as could be. She had contacted a psychic who skillfully talked her through the crisis. We psychotherapists may not be psychic, but there is more to our healing than our professional knowledge encompasses.
Hans Strupp conducted a study of psychotherapy offered to male college students suffering from anxiety, depression, and personality problems (Strupp and Hadley 1979). He compared the effectiveness of highly experienced psychotherapists with that of college professors selected for their ability to form understanding relationships with students. On average, patients from both groups showed similar levels of improvement. Emory Cowen (1982), one of my graduate school professors, conducted a study of the personal problems that clients present to divorce lawyers, hairdressers, bartenders, and industrial supervisors. The problems were highly similar to those that patients present to psychotherapists.
I doubt that the professors, lawyers, hairdressers, and supervisors would have comparable success to professionals with persons suffering from serious mental illness; we will not find randomized controlled trials in the literature. But we might ponder these questions: What knowledge do these community providers use? What knowledge did helpers of all sorts use before there were psychotherapists? Consider a parallel set of questions about patients: What knowledge must a patient have to engage in a productive psychotherapy relationship? What knowledge must a patient acquire during the process of effective psychotherapy?
I believe that the primary source of knowledge that psychotherapists bring to bear on their practice is derived from their history of relationships—close relationships most prominently. Here I include the relationship with oneself—personal knowledge at its most personal level. As is true of our patients, our personal knowledge is profoundly shaped by our culture, which, in turn, shapes our upbringing. Most of us are keenly aware of the particularly formative nature of early family relationships, the crucible for learning about ourselves and others. Yet our relational world quickly expands beyond the family, and we learn about relationships through a wealth of interactions throughout our lifetime. Patients bring their personal knowledge of relationships to the process, as do therapists, whose professional knowledge complements their knowledge from personal relationships. All of us learn a great deal about others through gossip—not malicious gossip but rather the ordinary conversations we have about other people, which comprise the greatest proportion of our conversations when we are not working with each other on tasks (Dunbar 1996). We learn from literature, film, theater, and art (Farber 2017). The mainstream media and social media provide a continuous stream of information (and misinformation) about our humanity (and inhumanity).
Apart from their professional knowledge, there is no reason to believe that therapists are better informed or educated than their patients in any of these nonprofessional domains, including personal relationships and interactions. Yet psychotherapists are immensely privileged in one respect: we are privy to a wealth of knowledge gleaned from intimate relationships with a potentially large number of patients who have trusted and confided in us. I have learned a great deal from patients about suffering and psychological problems, but I also have learned a great deal about human goodness, devotion, intelligence, imagination, wisdom, courage, and resilience.
Tacit Knowledge and Unconscious Processes
Polanyi (1966) distinguished two types of personal knowledge, the understanding of which is crucial to understanding the process of psychotherapy: explicit and tacit (implicit). When we think of knowledge, we are most inclined to think of what we express in language. When we engage in psychotherapy—talk therapy—we are concentrating on explication. Could we be overlooking a crucial dimension of the psychotherapy process? As Polanyi put it, “we can know more than we can tell” (p. 4).
Often enough, I think about what I am about to say to a patient. At times I deliberate. Sometimes I plan a strategy of interventions before I meet with the patient. Most of the time, however, we are having a relatively spontaneous conversation. Typically, I don’t know what I think until I have said it (at least to myself)—or written it. Invariably, with regard to all that goes into our interventions, we know more than we can tell—far more. In interacting with others, we rely on a wealth of prior experience and knowledge as well as a mass of perceptions and emotional responses to nonverbal cues that we could never explicate except in the most fragmentary way. Therein—in the tacit realm—lies a lot of the therapy. In drawing attention to unconscious processes, I intend primarily to make a humbling point: to a significant degree, our trustworthiness—and our patients’ perceptions of it—will be beyond our conscious control.
To a large extent, our unconscious knowledge is manifested in performance—dancing, riding a bicycle, playing the piano, catching a fly ball. Literally, we could not put one foot in front of the other without unconscious processes. We could not see, feel, think, speak, or add two numbers. I am partial to philosopher Daniel Dennett’s (2017) phrase “competence without comprehension” (p. 51). Such competence abounds, but because it is opaque to our awareness, we fail to appreciate it. Much of our competence develops unconsciously and escapes our notice. But it forms the foundation of trust, as I elaborate in Chapter 3.
Joel Weinberger and his colleague Valentina Stoycheva masterfully synthesized three centuries of literature on unconscious processes, with an emphasis on the burgeoning recent science (Weinberger and Stoycheva 2020). They characterized unconscious processes in the psychoanalytic models as being “affectively charged, nonrational, poorly integrated into the personality, and formed under the crucial impact of early experiences” (p. 50). Now we appreciate the far wider operation of unconscious processes, which are “normal and ubiquitous. Rather than being peripheral and unimportant, they are central and critical to psychological functioning” (p. 133, emphasis in original). They are central to our unconscious relational competence, in psychotherapy as elsewhere.
A common example of tacit knowledge pertains to the way we read emotional expressions in faces—sometimes unconsciously. For example, subliminal exposure to a threatening face can prime the observer to be more alert to danger, without being aware of the unconscious influence (Armony and LeDoux 1997). Might we become wary and distrusting of another person on the basis of facial expressions, vocal tone, and posture without being conscious of the reasons for our “gut feelings?” Might we quickly feel safe with a person without thinking about it? Will such intuitive responses influence trust in psychotherapy? Yes to all these questions, normally and ubiquitously. Will we be in control of either responding to these nonverbal influences or expressing them? A bit, perhaps. On the whole, however, we know each other, tacitly and implicitly, in ways we do not know.
Unconscious processes unfold automatically; they are relatively efficient, unintentional, and uncontrollable. They are based largely on repeated associations and habits. Much of this implicit learning is guided automatically in conjunction with emotion, most globally as it relates to a good-bad, approach-avoid dimension: “emotions grab our attention, help us organize our experiences, and play a major role in regulating those experiences” (p. 224, emphasis in original). We are also unaware of the extent to which our thinking is embedded in bodily experience, as represented in abundant metaphorical language: we “categorize people as warm or cold, feel distant or close to them, feel weighted down by stress, put too much on our plates, and feel our heads spinning” (p. 227). Our discourse in psychotherapy is filled with such metaphors—or should be, if it is to be vivid and evocative. When my colleague Michael Groat and I conducted an educational group to engage patients in understanding others’ internal worlds, we asked them to create a visual image of their experience in treatment. “Looking off the edge of a cliff,” “Hanging by my fingernails,” “Sinking in quicksand,” and “In a hole without a ladder” were typical examples. A patient struggling with bipolar disorder gave one of my favorites: “Trying to run up a down escalator.” We naturally and unconsciously link our emotional experience to our bodily functioning.
Unconscious processes can be problematic, for example, when we automatically extend relationship patterns from the past to present relationships where they no longer fit—the territory of misapplied distrust. In such instances, making the unconscious conscious to allow for new learning and memory has been a long-standing aim of psychotherapy. Conscious processing enables us to interrupt old patterns and to move into new ways of thinking, feeling, and acting in relationships. With repeated experience of trusting trustworthy persons, trust can become more automatic. We can make the conscious unconscious, as we do in developing skilled performance. To a large extent, the common relationship factors in psychotherapy require such skills, integrating conscious and unconscious processes. Because I am concerned about the complexity of relating in a trusting and trustworthy way, I underscore the balance between deliberation and intuition, with a conscious bias toward the latter.
Reconciling Left and Right (Hemispheres)
In establishing trust in psychotherapy, we should be mindful of lived experience as we endeavor to put so much into words. I find psychiatrist Ian McGilchrist’s (2019) distinction between the functions of the right and left cerebral hemispheres instructive—notwithstanding abundant crass popularization in which we are purported to do one sort of thing with our “right brain” and another with our “left brain,” as if they are disconnected (which would require neurosurgery). We must understand that “each hemisphere is involved in everything we do . . . . It’s not what each hemisphere does but how it does it that matters” (p. x, emphasis in original). The two hemispheres “work well together not because they have the same role, but precisely because they have different roles” (p. xv). The distinctive and complementary but potentially conflicting roles played by the right and left hemispheres add “to our understanding of our own minds” and “what it is to be a human being” (p. xxi).
Broadly speaking, the two hemispheres contribute to different takes on the world, based on the pattern of attention being narrow or broad, sustained or fluid: the left hemisphere illuminates a focus (foreground), and the right provides a sense of context (background). For example, when a therapist is conversing with a patient, she might be concentrating on what he is saying but is more subtly influenced by his facial expression and posture. The therapist can shift her attention from the patient’s speech to his body language, potentially bringing the body language into the foreground and leaving the speech in the background—perhaps not even listening to what he is saying but hearing the tone.
The following is a list of contrasts, left versus right, that I have drawn from McGilchrist’s review. I present some detail only to give you a feel for the pattern of differences, distinguishing throughout the focus of attention from the surrounding context. We have different relations: independent-interdependent, separate-connected, exclusive-inclusive, individualistic-pluralistic, decontextualized-contextualized. We can take apart or integrate, influence or empathize. We have different versions of knowing: abstract-concrete, general-particular, familiar-new, literal-metaphorical. We shift between categorizing and observing. We can take a physical or biological view: mechanical-organic, lifeless-living, static-dynamic, disembodied-embodied. We can shift between the neat and the messy: clarity-ambiguity, certainty-uncertainty, perfection-imperfection, simple-complicated, resolution-tension.
Having made these broad distinctions, McGilchrist devoted much of his book to making the case that the balance of power in our culture has shifted away from right-left complementarity to the dominance of the left hemisphere in shaping the way we think. Broadly, the right hemisphere serves a more experiential function and the left a more utilitarian function, exerting control over what we experience. McGilchrist titled his book The Master and the Emissary, arguing that the left (emissary) hemisphere should be the servant of the right (master), but the roles have become reversed, such that the servant has become the master (McGilchrist 2019). Ideally, he envisioned a process wherein the left hemisphere isolates something particular from its surroundings, illuminating an aspect of the context, thereby enriching our experience of the whole as well as allowing us to manipulate aspects of the world to exert control over it. Ironically, “The implicit has, now, to be made explicit. The catch is that in becoming explicit it is no longer the same at all” (p. xxiii).
When I speak and write about psychotherapy, I am focused on my thoughts about it, but these thoughts are continually grounded in my memories of experience with individual patients, and this experience is generally emotional. I speak and write about what I say to patients and what they say to me—it is talk therapy, after all. We need not create another battle in pitting the importance of what we say to each other (explicit, left hemisphere) against the direct experience of being with each other (tacit, right hemisphere)—the figure or the ground. The idea of a contest distracts us from the overall picture: both forms of attention, both ways of knowing, are crucial; they are intertwined continually, and they are best when mutually enhancing. My concern is that with all this talk, we are neglecting the profound importance of the direct experience of being together, the bedrock of implicit learning and the soil in which trust and distrust develop. Underground, this soil remains opaque to us, notwithstanding its being the ground floor of our trusting and trustworthiness.
I have reviewed how the field of psychotherapy is turning from trusting the treatment to trusting the relationship. What I have in mind here, in the psychotherapy relationship and other relationships, is the experience of presence, living engagement, the sense of the other person, the sense of self in relation to the other, and the feeling of understanding and being understood. The feeling of safety will be the bedrock of healing in the trusting relationship (Sandler 1960). Of course, the living experience can include the feeling of disengagement, disconnection, and misunderstanding as well as feeling threatened, wary, and unsafe. These experiences, largely tacit, will determine the fate of the therapy. Although we can never fully capture the experience in words, a crucial part of therapy is verbalizing the distressing experience in the service of overcoming it. Yet, if the talk is to be effective, it must have an impact on the lived experience that should be our greatest treasure. To return to McGilchrist’s metaphor, the left hemisphere must continually give back its comprehension to the right hemisphere’s experience.
Throughout this book, I keep coming back to problems in living. These problems have been the focus of ethical thought for millennia, and I think a crucial domain of the personal knowledge that we therapists bring to our practice is composed of ethical-moral thought. To a great extent, this knowledge has been articulated in the context of diverse religious traditions across the globe, and these traditions will have shaped the ethical thought of therapists and patients—consciously or unconsciously. Religious or not, this cultural heritage is part of our personal knowledge. In the following section, I superimpose ethical thought from philosophy on this broad cultural heritage.
Knowledge of Ethics
In this section, I make the case that a psychotherapist’s personal knowledge includes a sense of what constitutes psychological health. At a minimum, this ethical sense is implicit, but I believe that we psychotherapists should make our view of psychological health explicit, not only in our own minds but also in collaboration with our patients, whose views also should be cultivated, articulated, and prioritized in the work. We therapists might not be in accord with our patients about fundamental values, and finding common ground is part of the work. We have venerable professional allies in articulating what constitutes psychological health: philosophers who have developed the field of ethics over the course of more than two millennia in the West (the domain in which I am most knowledgeable).
To be less judicious in my language here, I think the professional literature as I have been reviewing it thus far fails to capture what I believe to be the essence of psychotherapy: its heart, soul, and spirit. Heart, soul, and spirit abound in my colleagues’ practice as I perceive and hear about it, evident in their devotion and caring, intermingled with their capacity for suffering along with their patients. But this essence tends to be sidelined in our professional discourse.
Accordingly, I have something radically different in mind from psychotherapists’ obligatory ethics codes and required events that focus on ethical practice. I am advocating a shift in attitude—a reorientation implied in my more temperate language of science-informed humanism. No doubt, professional ethical principles are compatible with ethical thought in philosophy, for example, including beneficence and nonmaleficence, fidelity and responsibility, integrity, justice, and respect for people’s rights and dignity (American Psychological Association 2017; Roberts and Dunn 2019). And conduct consistent with professional ethical codes certainly is essential to psychotherapists’ trustworthiness. But I have something broader in mind that relates to the major problem in psychotherapy research that has been the theme of this chapter: The focus on treating psychiatric disorders has overshadowed the need to work with the problems in living that play a major role in the development of these disorders. More than that, I think therapists should work from an intuitive and explicit sense of what a good life consists of, and they should engage their patients in that quest. In my view, trusting relationships are vital in a good life, especially when—inevitably—that life entails profound suffering.
Highlighting ethics in this section, I am setting the stage for my extensive use of philosophy in discussing trust and trustworthiness along with hope in subsequent chapters. Once we psychotherapists free ourselves from a narrow scientific and technological approach to our work, we need to anchor ourselves in a broader perspective on human life, with a grasp of how it goes well and how it goes badly. We psychotherapists are newcomers to this territory. We have established a foothold in endeavoring to help others with problems in living, but we are a small fraction of those who do so. We have science on our side, but we need much knowledge beyond science. If my experience is any guide, we will never feel that we have enough. Likely, we are not alone in that feeling. The following is a brief introduction to ethics—a small dose. I begin this section by using science to make the case for knowledge of ethics.
From Illness to Health
Sociologist Corey Keyes (2014) reviewed the World Health Organization’s advocacy for promoting mental health while giving due attention to the major contribution of mental illness to the global burden of disease. Mental health cannot be equated with the absence of mental illness; recovery from psychiatric disorder is not enough. Mental health must be considered a positive state. With roots in Aristotle (Bartlett and Collins 2011), Keyes used the term flourishing, which includes emotional, psychological, and social well-being. He characterized the absence of flourishing as languishing. As is true of mental illness, genetic and environmental factors interact in contributing to mental health.
Keyes envisioned mental health and mental illness as two intersecting continua, each ranging from low to moderate to high. He cited 2005 data from the United States indicating that at the high ends, the prevalence of mental illness was 17.5% and the prevalence of mental health was 22.4% (Keyes 2014). These two continua overlap to some extent, but they are relatively independent (sharing 28% of the variability). Accordingly, a person could be free of mental illness yet languishing; alternatively, one could be suffering from mental illness yet flourishing (and everything in between). As Keyes summarized,
Because there is some genetic overlap of mental illness and health, our findings suggest it may be somewhat more difficult to reach high levels of well-being if one inherits strong genetic risk factors for depression or an anxiety disorder. However, a strong dose of genetic liability to mental illness does not preordain individuals to low levels of well-being and inheriting a low level of genetic risk for mental illness by no means guarantees that an individual will flourish in life. (p. 184)
As ethicists have been advocating all along, flourishing is worthwhile in its own right. However, psychotherapists treating mental illness must be aware of a problem associated with focusing solely on recovery from illness: flourishing is protective against relapsing after recovering from episodes of mental illness. As Keyes documented, decreasing from a high (flourishing) level to a moderate level of mental health was associated with four times the likelihood of developing mental illness, and decreasing to a low (languishing) level of mental health was associated with eight times the likelihood of developing mental illness.
Keyes summarized what all psychotherapists should know: “gains in mental health resulted in decreasing odds of mental illness over time,” and “losses of mental health resulted in increasing odds of mental illness over time.” Accordingly, “If you want better mental health, you must focus on positive mental health—promoting flourishing and protecting against its loss. Public health and organizations cannot promote mental health by solely reducing mental illness, and no amount of wishful thinking will make this fact disappear” (Keyes 2014, p. 189).
From the perspective of ethics, shifting the focus from illness to health takes us back to Socrates. As philosopher Bernard Williams (1985) summarized, “It is not a trivial question, Socrates said: what we are talking about is how one should live.” Williams went on to say that “It would be a serious thing if philosophy could answer the question,” yet, “it is not true that philosophy, itself, can reasonably hope to answer it” (p. 1). But philosophy can help us think about it, and we should do so as psychotherapists.
I never had a patient entering psychotherapy with the question “How should I live?” Patients’ questions relate to more specific problems in living, problems in which troubles with close relationships often play a major part. Yet I have had numerous patients agonizing over the question, in one form or another, “Why should I go on living this life of unending misery?” This why question implies the how question for psychotherapy: How might life become worth living for me? When the question of suicide is not on the table, the explicit question “How should I live?” is in the (tacit) background. Whether I should live comes before how I should live. But the route to the whether is through the how. What is the possible path to a life worth living? I think therapists must have some vision of what makes a life worthwhile to get any psychotherapy off the ground. Moreover, this question is ethical and moral—the specialty of philosophers who are concerned about the problems of human life.
Ethics and Morals
Ethics and morals overlap, but it is useful to make a broad distinction, as Kwame Anthony Appiah (2008) neatly does: “I’ll generally follow Aristotle in using ‘ethics’ to refer to questions about human flourishing, about what it means for a life to be well lived. I’ll use ‘morality’ to designate something narrower, the constraints that govern how we should and should not treat other people” (p. 37). The entanglement of morals and ethics should be immediately clear: how we treat each other (and are treated by others) plays a major role in how well we live. Appiah puts it succinctly: “doing what is morally right is one of the constituents of human flourishing” (p. 168).
Compared with morals, ethics is a relatively neutral term, referring, for example, to a large domain of philosophical discourse about the quality of human life. We need to be able to hear the word morality without bracing ourselves for moralizing—a kind of judgmental, preachy attitude about right and wrong, good and bad. Here is Appiah’s conclusion about how ethics and morality fit together:
To see each other person not just as someone with preferences, pleasures, and pains, but as a creature engaged in the project of making a life, striving to succeed on the basis of standards that are partly found and partly made, you will see why you should keep promises and respect property, why you should not gratuitously obstruct other people’s ambitions or ignore their material, social, or psychological needs. Morality derives from an understanding of what other people are up to; it’s not a system of arbitrary demands. And the central thing that people are up to is the central ethical task: each of us is making a life. That is the human telos: to make a good life. (p. 203, emphasis added)
I think Appiah’s focus on making a good life is right on target as an ethical frame for psychotherapy. In making a life for ourselves, we must respect others as they do the same, and as psychotherapists we should actively promote their effort to do so. In my view, Appiah has articulated the ethical foundation of trustworthiness as it applies to psychotherapy and more broadly to social conduct.
When I taught abnormal psychology to undergraduates, I started by asking them for their ideas about contributors to mental health. I wrote the long list on the board. One semester, after we had generated a particularly long list, a bright woman in the back piped up: “Balance!” At first, I was a bit taken aback. Then her remark reminded me of one of Karl Menninger’s book titles, The Vital Balance. (Menninger 1963). Making a life for ourselves while attending to the life others are making for themselves is perhaps the most vital balance.
Owen Flanagan (2017) summed up the balance of ethics and morality neatly: we need “an ethical morality, a truly good way of living, of being human” (p. 106, emphasis added). To continue this theme, philosopher Christine Korsgaard (2009) penned one of my favorite passages in the ethics literature:
Your life fits into the general human story and is a part of the general human activity of the creation and pursuit of value. It matters to you both that it is a particular part—your own part—and that it is part of the larger human story. What you want is not merely to be me-in-particular nor of course is it just to be a generic human being—what you want is to be a someone, a particular instance of humanity. So it’s like this: in being the author of your own actions, you are also a co-author of the human story, our collective, public, story. As a person, who has to make himself into a particular person, you get to write one of the parts in the general human story, to create the role of one of the people you think it would be good to have in that story. And then—at least if you manage to maintain your integrity—you get to play the part. (p. 212)
A Good Life
If I could inspire you to read one science-informed philosophical book on ethics, it would be Daniel Haybron’s (2013) Happiness: A Short Introduction. Then you might be inspired to read his more extensive exposition, The Pursuit of Unhappiness (Haybron 2008). In what follows, I intend merely to highlight key aspects of his conceptual framework—the big picture that I think therapists would benefit from having in mind as they help their patients grapple with problems in making a life.
For much of his childhood, Haybron spent a few months of the year on “a small, isolated, and relatively undeveloped island, where at the time most residents earned their living from fishing” (Haybron 2008, p. xiii). The rest of the year he spent on the mainland. Life on the island was hard, and, by mainland standards, the islanders were relatively poor. Yet for Haybron, the island “is the only place I’ve felt at home . . . like a fully developed human being” (p. xiii). He went on: “fishing was hard work for little pay, and winters could be brutal. But even when working the most unpleasant job I’ve ever had, my times there were still wonderful” (p. xiv). The islanders were well acquainted with life on the mainland, but Haybron reflected, “I don’t believe many of them envied the far wealthier, and allegedly ‘freer,’ mainlanders at all” (p. xiv). Of the mainland, he observed, “The United States is, by a wide margin, among the most affluent nations in human history, and many Americans enjoy unprecedented freedom to shape their lives . . . . Yet no one ever accused us of ‘knowing how to live’” (p. 23).
These reflections provide the personal context for Haybron’s (2008) thinking about a good life, which he places at the top of his conceptual hierarchy: “an umbrella concept encompassing the domain of values that matter in a person’s life” (pp. 36–37). Living a good life should be one’s “ultimate goal in life” (p. 170)—“not just for one’s own sake, but period” (p. 171). Then comes the question, “What counts as a good life?” (p. 110).
Capturing what I consider the vital balance, Haybron distinguished two contributors to a good life: 1) well-being, which is more individual, and 2) morality and virtue, which are more social. Both contributors are key concepts in any ethics. Morality and virtue will not be foremost priorities on any psychotherapy patient’s mind, and I would consider a patient’s desire to become more virtuous worthy of much reflection. Although I have found the broad philosophical school of virtue ethics (Hursthouse 1999) to be of enormous value in thinking about psychotherapy, I will set virtue aside here and stick with morality—which is sufficiently off-putting to many in its own right.
Rather than morality, of first concern to patients and therapists will be well-being and happiness, and to these Haybron has devoted a great deal of thought. Haybron declares his values regarding the vital balance between well-being and morality: “I want not merely for my children to be well-off or flourish; I want them to be good people and conduct themselves well, whether or not it benefits them. In fact this seems more important than their wellbeing” (p. 160, emphasis in original). Well-being, the predominant target of psychotherapy, entails the extent to which your life is “good for you” (Haybron 2013, p. 110, emphasis in original). Subjective well-being includes your personal experience and how you feel, whereas objective well-being fits normative standards, such that others could recognize it—perhaps better than you might. Thus, well-being includes being well, feeling well, and functioning well—what a parent would wish for a child, and what a psychotherapist would wish for a patient. Especially pertinent to psychotherapy is Haybron’s (2008) point that an individual’s well-being captures what others who provide help are aiming for: “what it is rational to want for someone insofar as one cares for her” (p. 40)—we would want the individual to be making a good life.
Haybron (2008) places self-fulfillment—“living in a manner that conforms to the sort of person one is” (p. 180)—as the core of well-being. Conversely, an unfulfilling life would be one lived in conflict with one’s nature. Consider, for example, an attorney in a chronically high-stress life, hell-bent on achieving status and acquiring wealth, who might be much better off in a more self-fulfilling—if lower-paying—pursuit such as teaching that would be more rewarding and allow for more leisure. What constitutes self-fulfillment depends on the idiosyncratic makeup of the individual, and it is contingent on the individual’s success in his or her endeavors, which will always be somewhat chancy.
Haybron (2008) construes happiness as a major contributor to well-being, but he ranks it beneath morality in a good life: “to sacrifice the demands of good character in the name of personal happiness—or, I would add, personal welfare—can never be justified. We must, above all, act decently, if not well” (p. 123). More explicitly, morality “is clearly the most important part of the picture, and the most important thing to get right in a good life” (Haybron 2013, p. 111). Moreover, while recognizing the importance of happiness to well-being, Haybron is not content with its popular construal: “the popular ‘smiley-face’ stereotype of happiness . . . grossly distorts and oversimplifies the phenomenon: happiness has a much richer, deeper, more complex, and less obvious psychology . . . . Cheery feelings matter, and do not deserve the abuse so often heaped on them, but they are a relatively uninteresting part of the story” (Haybron 2008, p. 106).
Haybron (2008) construes happiness more broadly as an emotional condition, “the aggregate of a person’s emotions and moods” (p. 109). From the perspective of your emotional condition, the role of feeling happy “is grotesquely exaggerated in the popular imagination, doubtless accounting for much of the scorn heaped on happiness.” Consider that “most happy people don’t feel happy most of the time” (p. 109, emphasis added). Your emotional condition is a relatively enduring disposition to respond to the world, evident in feelings (including at the visceral level), ways of thinking, and behavior (e.g., expressions and tone of voice). On the negative side, your emotional condition might be depressive, anxious, or irritable; on the positive side, you might be characteristically more serene or in good spirits.
Without dismissing it, Haybron ranks feeling happy as least important in one’s emotional condition. Second in importance to Haybron is energetic engagement with life, “enthusiastically taking up what it has to offer” (p. 114). Here he includes Mihaly Csikszentmihalyi’s (1990) concept of flow, which refers to your experience when you are actively immersed in activity that optimally balances skill and challenge: too little challenge, and you are bored; too little skill, and you are anxious (or worse, if scaling a mountain).
No reader will be surprised that feeling happy and being actively engaged with life play a significant role in your emotional condition. But Haybron insightfully shifts our perspective to the cardinal value of attunement as the core of happiness. Think of attunement as being in tune with your life, a kind of harmony. As a therapist who has specialized in treating trauma, I find Haybron’s prioritizing safety and security in this context to be right on the mark. He prioritizes tranquility over the more obvious positive emotions: “we might think of tranquility as ‘settledness’: not merely peace of mind or lack of internal discord but a kind of inner surety or confidence, stability and balance, or imperturbability . . . . [T]ranquility presents itself in the relaxed, easy posture” (p. 116). Attunement entails feeling at home in your life and, in a relationship, at home and in sync with the other person. Attuned, you have a sense of familiarity and goodness-of-fit in your life, which comes with feelings of confidence and mastery. You can let down your defenses and, in turn, blossom with feelings of openness and expansiveness. Perhaps most importantly, such attunement provides you with a sense of freedom.
We psychotherapists and our patients are all too familiar with lives that fall short of the good life that Haybron so richly describes. We all face myriad potential hazards, which include emotional ignorance. Haybron’s (2008) review of recent psychological research shows that we are not particularly good at identifying our past emotional conditions, nor are we adept at anticipating our future emotional states. Worldwide surveys typically show a vast majority of Americans reporting high levels of happiness (e.g., 96% in one large study). Haybron finds these results impossible to believe in light of other studies showing Americans reporting high levels of stress, depression, and loneliness (e.g., half of respondents have no friends in whom they confide and a quarter have no confidants at all). Suicide rates are on the rise (Stone et al. 2018). The American dream might be just that.
With the pursuit of unhappiness in mind, Haybron (2008) proposed the central thesis that “people probably do not enjoy a high degree of authority or competence in matters of personal welfare. We should expect them systematically to make a host of serious mistakes regarding their own well-being. Surprisingly often, people’s choices may frustrate their prospects for happiness and well-being rather than improve them” (p. 13). Haybron does not question our right to make such choices; rather, he questions the two pillars of our authority: 1) the transparency assumption, that “what’s good for a person is relatively easy for that individual to discern,” and 2) the aptitude assumption, that “people typically have the psychological endowments needed to choose well given the broad ability to live as they wish, with a rich array of options” (pp. 13–14). Consider the odds: to lead a life well “requires more than a numerical majority of good choices, since even one bad choice can ruin one’s life” (p. 13). Accordingly, Haybron proposes a systematic imprudence thesis:
Human beings are systematically prone to make a wide range of serious errors in matters of personal welfare. These errors are weighty enough to substantially compromise the expected lifetime well-being for individuals possessing a high degree of freedom to shape their lives as they wish, even under reasonably favorable conditions (education, etc.). (p. 227, emphasis in original)
Here the potentially pernicious social conditions that have driven all the ethicists over the ages to do their work come into play. An abundance of freedom and an abundance of choice, coupled with potential emotional ignorance, can set us up for failure in the pursuit of happiness. Haybron enumerates the scope of choices we might make: career, life partner, having children, how to raise children, balancing work and relationships, choice of friends, use of leisure time, choice of hobbies, where to live, managing finances, what education to attain, and what talents to develop, just to mention the more obvious ones. I would add the abundance of substances we can ingest, including food and medications. To reiterate, one bad mistake or a series of bad judgments can seriously compromise, ruin, or end your life.
I think Haybron has made a substantial contribution by synthesizing a number of recurring themes in the history of ethics, rehabilitating the concept of happiness in the process. He has drawn our attention to some of the ways that the pursuit of happiness can go wrong, leading to problems in living that can contribute to psychiatric disorders, the common route to a psychotherapist’s office. And he provides a remarkably succinct and coherent framework for thinking about what a psychotherapist would need to consider, not only to help patients find their way out of illness but also to help them become well (Keyes 2014). To bring to mind Aristotle’s archery metaphor, if we are to achieve our aim, we must have a target (Bartlett and Collins 2011). Haybron has given us a target, albeit not a smiley face that could be drawn on a big sheet of paper.
Positive Psychology
Martin Seligman (2011), who had been well known for his pioneering work on learned helplessness as the basis of depression, took a 180-degree turn:
I have spent most of my life working on psychology’s venerable goal of relieving misery and uprooting the disabling conditions of life. Truth be told, this can be a drag. Taking the psychology of misery to heart—as you must when you work on depression, alcoholism, schizophrenia, trauma, and the panoply of suffering that makes up psychology-as-usual’s primary material—can be a vexation to the soul . . . . If anything changes in the practitioner, it is a personality shift toward depression. (p. 1)
Yet positive psychology represents far more than an emotional preference for the light over the dark. Seligman’s widely embraced movement has made a significant contribution to addressing the problems Keyes (2014) identified, with an exclusive focus on illness to the neglect of health: “the absence of ill-being does not equal the presence of well-being” (Seligman 2018, p. 5). Relieving suffering is insufficient: “While not much of a therapist, I sometimes did good work, and in those cases, my patients’ negative emotions were normal by termination. Did I get a happy patient? No, I got an empty patient”—not ill, but languishing (p. 206). Positive psychology provides an impetus and some methods for a more balanced psychotherapeutic approach.
Seligman (2011) turned to ethical thought as a guide for promoting health. In line with Appiah and Haybron, he proposed that “psychology could be explicitly about building the good life” (Seligman 2018, p. 5, emphasis added), and he proposed that “the goal of positive psychology is to increase flourishing” (Seligman 2011, p. 13). Eschewing the equation of happiness with cheerful feelings, he reframed his thinking as well-being theory, emphasizing eengagement, achievement, and finding meaning in something larger than oneself. He referred to the words of a colleague: “When asked what, in two words or fewer, positive psychology is about, Christopher Peterson, one of its founders, replied, ‘Other people’ ” (p. 20). Seligman’s work is particularly pertinent to psychotherapy for its methods designed to actively promote flourishing. Positive psychology employs various self-assessments to guide activities geared to promoting the individual’s well-being according to his or her values and strengths. Seligman and his colleagues have developed interventions to enhance well-being and implemented them in diverse settings, including general medical populations, schools, and the military (Seligman 2018).
Philosopher Michael Bishop (2015) criticized positive psychology for proposing lists of contributors to well-being without an organizing theory. Bishop advocated an empirical approach that would study how various contributors to well-being (on positive psychology’s list) are related to each other dynamically in networks of connections. From a clinical-developmental perspective, I find Bishop’s approach appealing because I aim to identify cascades of events and experiences. I am all too familiar with cascades of adversity. For example, early traumatic events, self-destructive behavior, abusive relationships in adulthood, turning to substance abuse as a way of coping, insomnia resulting in an inability to concentrate, profound depression, and loss of livelihood might all end up with a person feeling alone and suicidal. Bishop envisioned positive cascades: for example, extroversion and optimism contribute to social support; social support and hard work contribute to academic success; this success eventuates in occupational attainment and job satisfaction; in turn, this history of positive relationships and success contributes to the development of an enduring relationship, which also stabilizes occupational functioning. Good works are an end result.
My reservations about positive psychology concern not its substance but rather the misguided attitude with which it might be implemented by inexperienced enthusiasts. My concern comes from conducting psychoeducational groups with patients suffering from residual depression associated with childhood trauma. When I enumerated various ways in which they could improve their mood, patients objected that these strategies did not work. They were too depressed to use them. They tuned me out. I learned to start these discussions with what I called the catch-22s of depression (Allen 2006): All the things you need to do to recover from depression are made difficult by the symptoms of depression. For example, you should get sufficient sleep, but you suffer from insomnia; you should socialize, but you are withdrawn; you should exercise, but you are fatigued; and you should engage in enjoyable activities, but you lack the capacity for pleasure. When I began with the catch-22s, the patients listened. When patients are in the process of recovery, pep talks and cheerleading will not do; we start with negative psychology. As the research on health and flourishing attests, however, we should not end there.
Mastering the Craft of Psychotherapy
Earlier in this chapter I summarized research showing substantial differences among therapists in treatment outcomes. Moreover, differences among therapists are greater than differences among types of treatments. Knowing about therapist effects requires that we turn our attention to effective therapists. Accordingly, Castonguay and Hill (2017a) titled their book How and Why Are Some Therapists Better than Others? The most prominent research on psychotherapy over the past half-century could be presented under the same title if “Treatments” were substituted for “Therapists.” That volume could conclude with a disappointing chapter on the dodo bird verdict, along with the recommendation that the field should have been paying much more attention to therapists.
Here we are squarely in the territory of what constitutes conscientious therapy and what makes us therapists trustworthy providers of treatment. To me, many of the research findings I present in this section are disconcerting if not downright discouraging. Surely, they couldn’t apply to me! I am reminded of extensive experience on oral examination committees for graduate students who were defending their master’s and Ph.D. theses. All too often, when their results had failed to confirm their cherished hypotheses, they criticized their research methods and held on to their prior beliefs. They ignored the data. True, science advances by self-criticism. Personal knowledge also increases by self-criticism. To be trustworthy, we psychotherapists should not take our trustworthiness for granted. Taking research seriously will help therapists develop reasonable self-trust, relationship by relationship.
Art and Craft
This is the place to amplify a distinction I introduced in the “Introduction.” I was invited in 2004 to give a lecture on psychotherapy at Smith College, during which I protested the attempted takeover of psychotherapy by science. At the end of the lecture, a psychologist in the audience, Laurie Pearlman, challenged my protest by pointing out that my lecture was based on findings from science. Afterward, Gerry Schamess, the editor of the college’s social work journal, invited me to submit a manuscript based on the lecture, which I titled “Psychotherapy: The Artful Use of Science” (Allen 2008). Subsequently, I came across a different way of thinking, proposed by Jeremy Holmes (2010), who began, “Psychotherapists enjoy debating whether . . . their discipline is an art or a science.” (Apparently, I had been debating myself.) To reiterate, Holmes had a better idea about psychotherapy: “It is perhaps better seen as a craft . . . drawing on both art and science but distinguishable from both” (p. x, emphasis added).
Holmes elaborated several characteristics of crafts: they cannot be learned from books; they require apprenticeship; they are comparatively noncompetitive; and their practitioners form communities or guilds stipulating rites of passage. No doubt, there is art in craft, and psychotherapy should be guided by science but not dominated by it. As I stated initially, I find the word craft especially appealing inasmuch as I consider mastering a craft to be the work of a lifetime. Now, more than 50 years after I saw my first patient, I would say confidently that I never felt that I had mastered the practice of psychotherapy. But I think that mastering the craft is the right aspiration, and that aspiration focuses our gaze on the personal and professional development of the therapist. I am partial to the psychotherapy integration effort because I think it captures what naturally should be a developmental progression. We might think of trustworthiness as the most integrative aim of our development as therapists. We might view becoming locked into a narrow treatment approach as a developmental arrest.
In thinking about how therapists might go about mastering the craft of psychotherapy, we need a criterion for gauging progress. How can therapists improve without knowing if they are improving? The criterion of choice throughout the prior discussion has been treatment outcomes. Research on common factors and individualizing treatment as well as identifying differences among therapists in effectiveness has employed outcomes assessments. As described next, employing such assessments throughout the course of treatment along with providing ongoing feedback to therapists and patients has been shown to improve treatment outcomes. In this context, we might think of therapists’ reasonable self-trust as being informed by data.
Outcomes Assessment and Feedback
A number of methods for assessing treatment outcomes have been adapted to track progress on a session-by-session basis and to provide immediate feedback to therapists and patients. Some of these assessments also include patients’ perceptions of the therapeutic alliance. Clinicians should be aware that structured questionnaires have been developed for patients to provide feedback to therapists about important events in the session: what was helpful, what they did not like, what they are learning, what actions they are taking, what they want to work on, and so forth (McLeod 2017). But research has focused on quantitative assessments that lend themselves to computerized administration (Chapman et al. 2017; Lambert et al. 2019).
Extensive research shows that feedback over the course of therapy improves treatment outcomes, especially by identifying patients who are at risk for deteriorating in treatment. This finding is extremely important because deterioration in therapy is a significant problem, representing 5%–10% of patient populations (Lambert et al. 2019). Moreover, compared with objective assessments, therapists are overly optimistic about patients’ progress and notoriously poor at detecting patients who are worsening in therapy (Chapman et al. 2017; Lambert et al. 2019). For such patients, the objective data provide an opportunity for much-needed correction. Of course, the value of the feedback process hinges on its implementation. The major problem is clinicians’ reluctance to employ outcomes assessments. Yet it is also problematic when the measures are used perfunctorily, for example, not discussed with patients or not employed to guide the therapy (Maeschalck et al. 2019).
Professional Experience
Is accumulating experience a solid basis for therapists’ self-trust? The contribution of therapists’ experience to their clinical effectiveness has been a topic of long-standing research interest. Simon Goldberg and colleagues’ (2016) review of the literature showed somewhat mixed results. Older studies suggested a moderate positive relationship between experience and effectiveness (i.e., fewer dropouts and better outcomes). More recent studies, however, have yielded a more disconcerting finding: they have “generally failed to detect superior outcomes for more experienced clinicians relative to trainees or less experienced therapists” (p. 2). As the authors noted, all this prior research has been cross-sectional, comparing groups of more versus less experienced therapists, often indexed by years since degree. Such studies do not control for such factors as predegree experience or number of patients seen annually. Preferable would be a longitudinal design in which therapists could be followed individually over time, comparing their effectiveness at an earlier point with their later effectiveness. Such a study could directly reveal a developmental progression.
The authors used a longitudinal design to investigate changes in a large set of psychotherapists’ effectiveness over the course of their practice at a university counseling center (Goldberg et al. 2016). The data, obtained over an 18-year period, included 170 therapists, 6,591 patients, and more than 50,000 sessions. The results showed an overall decline in effectiveness over time (i.e., more clinical experience was associated with poorer outcomes), although greater experience was associated with fewer dropouts. Yet these differences were very slight; for all practical purposes, there was a minimal relation between experience and effectiveness. Notably, there were individual differences among therapists: about 60% showed a decline with experience, whereas about 40% showed improvement. But all these differences were modest in extent.
Goldberg and colleagues (2016) acknowledged several limitations in their study. All the patients were college students and did not show serious mental illness, for which therapists’ experience could play a greater role in effectiveness. Moreover, the authors studied only the quantity of experience (duration of practice and number of patients seen) and not the quality or type of experience. Perhaps most important from a developmental perspective, the duration of experience between measurements was relatively modest. Before the first assessment, the therapists had an average of 5.15 years of experience since beginning graduate school. Although the range of experience at the counseling center in the group of therapists was substantial (from about a half-year to 18 years), the average level of acquired experience across the study was less than 5 years (and the median was only about 2.5 years). From my vantage point, that is a drop in the bucket.
Shifting from the experience of individual therapists to the profession as a whole, we might wonder about the extent of improvement in psychotherapy outcomes across time. Is the field of psychotherapy mastering its craft? Wampold’s analyses of decades of meta-analyses showed that the size of treatment effects has been remarkably consistent across time (Wampold and Imel 2015). As Scott Miller and colleagues (2017) summarized, “for close to four decades the outcome of psychotherapy has remained flat” (p. 23). This finding implies that, as a group, we have not improved with experience, despite having developed hundreds of new treatments over recent decades. Remember, however, that this averaging process—homogenizing fruit salads into smoothies—could obscure improvements in the treatment outcomes for some disorders associated with specialized approaches.
Limitations notwithstanding, this research on professional experience should give us therapists pause. Not only have we not mastered the provision of psychotherapy; we are not even on a common developmental course of mastering it—individually or collectively. To be hard-nosed about it (which I rarely am), if we therapists want to believe that our experience practicing psychotherapy has made us more effective, we are relying on faith. I have no objection to faith, but I think the most serious problem lies with the profoundly vague term experience. Continuing to conduct mediocre therapy in the same way for several decades will not be of great help. Apparently, we need a different kind of experience. We need to consider this question: what kinds of experience will contribute to developing greater effectiveness over time?
Supervision, Consultation, and Continuing Education
In principle, the course of professional development should be facilitated by supervision, consultation, and continuing education. As Rodney Goodyear and colleagues (Goodyear and Rousmaniere 2017) distinguish the first two of these practices, therapists require supervision in their training to be competent for professional licensure, such that the supervisor serves an evaluative and gatekeeping function, whereas qualified therapists seek consultation voluntarily to enhance their effectiveness and expertise. Jennifer Taylor and Greg Neimeyer include consultation and continuing education as forms of continuing professional development in the service of lifelong learning, defined as “an active, continuous quest for knowledge, growth, and development” (Taylor and Neimeyer 2017, p. 219). Are these methods of promoting professional development demonstrably effective? Are they a sufficient basis for patients’ trust and therapists’ self-trust?
Gauged by the criterion of improving treatment outcomes, the research literature on the effectiveness of routine supervision is not encouraging, and evidence is lacking that supervisors’ level of experience or professional qualifications make a difference (Goodyear and Rousmaniere 2017; Miller et al. 2017). This finding, however, must be considered in light of the fact that supervision commonly relies on unstructured discussion of cases, the value of which depends on supervisees’ memory as well as their willingness to disclose problems in the context of being evaluated. As in psychotherapy, the willingness to disclose will be contingent on the quality of the supervisory relationship and the supervisory alliance. To compensate for these problems, reviewers advocate the use of audio and video recordings as well as live supervision.
Although the success of supervision in facilitating professional development is the exception rather than the rule, some research has shown that supervision can be effective. For example, using supervisees’ outcomes assessments in supervision has been shown to improve treatment outcomes (Reese et al. 2009). Mark Hilsenroth and Marc Diener developed a model of supervision with the aim of fostering skill in the practice of manual-guided psychodynamic psychotherapy (Hilsenroth and Diener 2017). They employed discussion of videos to foster the skilled use of interventions. Building on their prior research showing that psychodynamic interventions interact with the alliance to improve treatment outcomes (Owen and Hilsenroth 2011), they demonstrated that this theory-guided, systematic supervision enhanced the therapeutic alliance.
As Taylor and Neimeyer (2017) reviewed, the history of continuing education in psychology dates back to the 1940s but began to be widely mandated only in the 1990s. Assessment of the effectiveness of continuing education generally is limited to reports of participant satisfaction; no research shows a relation between satisfaction with continuing education events and improvements in clinical practice. Moreover, “The majority of [continuing education] programs are offered as didactic seminars . . . even though research indicates that passive learning from didactic presentation does not facilitate long-term learning and registers minimal impact on skill acquisition or client outcomes” (p. 225). Consistent with didactic methods, the authors point out critically that continuing education is “geared toward knowledge retention rather than skill acquisition” (p. 230, emphasis in original). With McGilchrist (2019) in mind, we might say that knowledge acquired by the left hemisphere (e.g., from the book you are now reading) will be of little value if not put to use by the right hemisphere in living your life.
Where does this leave us psychotherapists who have invested so much in training and continued learning? Miller and colleagues (2017) offered this appraisal:
When it comes to professional development, two facts are apparent. The first, to the credit of practicing psychotherapists worldwide, is that they want to get better at what they do. This is not only a shared goal; it is a core value. The second is that the traditions and practices informing and comprising professional development do not work. When it comes to improving outcomes, the time, money, and effort expended—even mandated by licensing and certification bodies—are largely wasted. The overall effectiveness of psychotherapy has remained stagnant, and the results of individual clinicians do not improve with time, training, and experience. (pp. 35–36)
We should be grateful for decades of research demonstrating that psychotherapy is effective. But we should not be complacent about improving our work with traditional methods of continuing professional development, much less with the mere accumulation of time in the saddle. We can derive some hope from one agency-wide model of clinical consultation that was integrated with routine outcomes assessments and feedback.
Goldberg and colleagues (2017) conducted an ambitious and instructive study of ways to improve psychotherapists’ performance in a community mental health center and training clinic in Calgary, Alberta, Canada. Throughout the project, therapists were assured that their data would not be used in individual performance evaluations. In the 2-year pilot phase, the researchers collected data on two measurement systems to determine the feasibility of data collection. They used objective measures to assess patients’ functioning and the therapeutic alliance. Both measures were employed on an agency-wide basis in each session. For the first 4 years, the data were used solely to provide annual statistical reports on outcomes for the agency’s purposes.
Although the procedures had been integrated into the agency infrastructure, it became apparent after 4 years that data were being collected for only 40% of the clients (Goldberg et al. 2017). Many therapists objected to the procedure, for example, because of the extra paperwork involved and their assumption that clients would not like to complete the measures and because they already had clinical feedback about the progress of therapy. The agency then stated the policy that therapists could not opt out and would be held accountable for integrating the assessment into their practice. After this new policy was announced, 40% of the therapists resigned. When therapists were hired to replace those who had left, they were informed about the agency culture of feedback.
Along with this agencywide mandate, two monthly consultation groups were implemented, one for students and the other for staff members. These groups were led by an outside consultant, and therapists presented outcome graphs along with their clinical material. After 8 months, the administrators learned that some therapists were presenting only cases that were going well, and they implemented a new policy that therapists must present cases that were not going well according to the outcomes data (Goldberg et al. 2017). Four more staff members resigned (which was relatively few, compared with the previous exodus). The consultation groups then focused systematically on problematic cases. From these group discussions, the therapists developed an understanding of common problems and ways of addressing them. In addition, every 4 months, all of the therapists were provided with summaries of their individually aggregated outcomes data (i.e., number of clients seen, average number of sessions, average outcomes scores at admission and termination, and average extent of improvement). They also were given the agencywide data for the same period so that they could compare their individual outcomes with those for the psychotherapist group as a whole.
This project is especially worthy of attention because it runs counter to the general findings that individual therapists’ extent of experience as well as the experience of the field in general (over four decades) are not associated with improved outcomes. As the authors summarized their findings, in this agency, the outcomes were improving from year to year: “clients who came to the [clinic] in 2014 would be predicted to have larger gains over the course of treatment than those who came in 2010.” Moreover, “therapists were getting better over time . . . a client seen by a given therapist in the therapist’s fifth year at the agency would be expected to show larger drops in reported symptoms over the course of therapy than a client seen by that same therapist in the therapist’s first year at the agency” (Goldberg et al. 2017, p. 208, emphasis in original). Contrary to Goldberg and colleagues’ earlier study, this project demonstrated that “Therapists can improve over time” (Goldberg et al. 2017, p. 209, emphasis in original). This improvement, however, was contingent on a monumental (and costly) agency-wide culture shift that included three key features: 1) detailed and synthesized feedback, 2) a focus on patients who were not doing well in treatment, and 3) an opportunity to learn from peers and a consultant about ways of intervening. With clinical outcomes as a criterion, I view this as a deliberate effort to improve the agency’s trustworthiness by means of changing individual clinicians’ practice.
Deliberate Practice
A number of psychotherapists interested in professional development have taken cues from the literature on developing expert levels of skill in other domains, such as sports, musical performance, chess, and medicine. The key to improvement is deliberate practice—lots of it. As Miller and colleagues (2017) characterize it, such practice entails a lifelong deliberate effort to improve, which requires seeking out challenges that go beyond one’s current abilities. Such practice typically is not enjoyable; it is effortful. As measured by treatment outcomes, the top 25% of therapists spend nearly three times more hours per week engaging in deliberate practice than do the bottom 75%. Miller and colleagues advocate a cycle of excellence that entails “(a) determining a baseline level of effectiveness; (b) obtaining systematic, ongoing, formal feedback; and (c) repeatedly engaging in activities specifically designed to refine and improve performance” (p. 30). Goldberg and colleagues’ (2017) project meets these criteria.
Reviewing the literature on expertise, Franz Caspar (2017) characterized master therapists as voracious learners and asserted that “the best chance of optimally learning from experience exists when therapists have clear, explicit, theoretically driven, individual case conceptualizations serving as a basis for interpreting information emerging in the course of psychotherapy” (p. 208). However, no single form of deliberate practice has been linked to effectiveness; rather, a range of activities make a contribution. These include working on case formulations, attending training workshops, thinking about difficult cases, preparing and reflecting on sessions, reviewing recordings of sessions, role-playing, seeking consultation, and collaborating with colleagues in developing skills (Caspar 2017; Miller et al. 2017). More generally, this effort requires a supportive social context in a culture of excellence (as Goldberg and colleagues’ mental health center project illustrates).
Compared with other domains of expertise, deliberate practice in psychotherapy is far less straightforward. Psychotherapy does not provide immediate feedback about the effectiveness of our actions. I know immediately (and often) when I hit a wrong note on the piano. In psychotherapy, our main objective criterion for effectiveness is treatment outcome as measured by improvement from admission to termination as well as status at termination (and follow-up)—delayed feedback indeed. Just as problematic is research reviewed throughout this chapter showing that no specific treatment methods or techniques uniquely relate to treatment outcomes. Skill can be measured by adherence to treatment manuals, but adherence is not enough. For example, a study of cognitive-behavioral therapy that involved 300 hours of intensive training, supervision, and practice found that adherence and competence were unrelated to outcome (Rounsaville et al. 2017). Accordingly, some authors have proposed that flexibility in adherence relates more highly to treatment outcomes than does strict adherence (Hilsenroth and Diener 2017).
In sum, we therapists know that we should practice—intentionally and deliberately—but there is no particular method or skill that can be prescribed for practice. We are back to an inherently individual developmental process. The skills we might practice will depend on the treatment methods we have chosen. Given the dodo bird verdict, outcome research cannot guide these choices. If we are to avoid professional developmental arrest, we need to follow a path of psychotherapy integration. Like our patients (when they are fortunate), we follow our treatment preferences. Perforce, we will practice some methods and techniques, more or less deliberately. We cannot take our trustworthiness for granted; we must work at it.
Here I must insert a crucial caveat: for many practitioners who are loaded up with clinical work on top of other personal responsibilities, time for deliberate practice is a luxury beyond reach. If we take Goldberg’s work (Goldberg et al. 2017) as a model, a high level of institutional support is required. I have been fortunate to have plenty of it (along with family forbearance).
Interpersonal Skill
If we are to judge from the psychotherapy research literature reviewed early in this chapter, interpersonal skills are more important than any particular technical skills because interpersonal skills influence the effectiveness of any particular methods we might practice. For example, Caspar (2017) summarized research showing that “the ability to communicate in an unambiguous and clear way, empathy, respectful warm contact, the ability to deal with criticism, the ability to cooperate, and interpersonal competence were correlated with fewer dropouts and better outcomes for patients” (p. 203). Similarly, enumerating facilitative interpersonal skills, Wampold (2017) listed emotional expression, persuasiveness, hopefulness, warmth, empathy, alliance-bond capacity, and problem focus. He also noted the importance of verbal fluency: plainly, communicating clearly and succinctly plays a pervasive role in our talk therapies, and fluency is “critical for providing a believable, succinct, and adaptive explanation and a cogent rationale for the therapeutic actions” (p. 57). Interpersonal skill plays a major role in the development of a therapeutic alliance and in repair of ruptures. William Stiles and Adam Horvath asserted, “A strong alliance is not a technique but an achievement, one that requires doing the right thing over a period of time” (Stiles and Horvath 2017, p. 78, emphasis added). Interpersonal skill plays a crucial role in this achievement.
There is an intriguing finding that I believe to be associated with the quality of the therapeutic relationship. Psychotherapists’ reports of professional self-doubt (i.e., doubts about their effectiveness) are associated with better therapeutic alliances (Nissen-Lie et al. 2010) and treatment outcomes (Nissen-Lie et al. 2015). As Wampold (2017) understood it, such self-doubt is an indication of reflectiveness about one’s work. I interpret self-doubt as an indication of humility, which, to me, is utterly realistic in light of limitations in our knowledge and skill. Self-doubting therapists apparently have not succumbed to the more common tendency to overestimate their effectiveness (Boswell et al. 2017). They are self-critical, a basis for trustworthiness. Accordingly, self-doubt likely contributes to greater awareness of problems and mistakes along with motivation to improve.
Last, we should not neglect the role of self-care in therapists’ competence and trustworthiness (Taylor and Neimeyer 2017). Practicing psychotherapy is stressful, and it is associated with high rates of burnout, depression, relationship problems, substance abuse, and suicide. Working for many years in an inpatient program tailored to professionals in crisis, I saw these problems firsthand in mental health professionals. I particularly enjoyed working with psychologists, but I was continually struck by their failure to practice what they were preaching, often in the context of overwork. Ideally, we therapists would be free of illness and high on the continuum of health—flourishing. Ideally. We need to apply our interpersonal skill to our own personal development and well-being, not least to developing and maintaining stable and supportive relationships that can sustain us in this demanding work. Practicing what we preach, we should be open to receiving psychotherapy as well as offering it, knowing of its effectiveness.
In the context of treating trauma in attachment relationships, I proposed that our paramount competence is skill in being human (Allen 2013c), the essence of which is our uniquely human capacity for social connection and cooperation. Taking seriously the role of personal knowledge in conducting psychotherapy—including our implicit (nonverbal) capacity for relating—I would argue that our developmental trajectory as psychotherapists begins in infancy. Apart from the most highly manualized, technical approaches to symptom reduction, our acquisition of professional knowledge and specialized skills is of limited value without skill in being human. Mastering that skill is the work of a lifetime, and we will fall short to varying degrees. We best develop the skill of being human in the context of trusting and trustworthy relationships starting early in life.
Summary of Key Points
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Therapists, patients, and students recognize the importance of trust in psychotherapy, but comprehensive thinking about trust is rare in the therapy literature.
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Attention to patients’ distrust overshadows what should be the foundation for their trust: therapists’ trustworthiness.
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The continuing development of hundreds of brands of therapy runs counter to the long-standing research finding that the quality of the patient-therapist relationship contributes more to the treatment outcome than do the theoretical approach or specific methods employed.
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Psychotherapy is best adapted to more than patients’ psychiatric disorders and symptoms, including cultural differences (e.g., race, ethnicity, religion); sexual orientation and gender identity; readiness for change; and treatment preferences.
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Differences among therapists contribute more to treatment outcomes than do differences among treatment methods, such that we should pay less attention to the development of methods and more attention to the development of therapists.
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Conducting therapy requires personal knowledge along with professional knowledge, and personal knowledge includes knowledge of ethics, which is essential to going beyond alleviating illness to promoting health.
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Psychotherapy is best considered a craft, and mastery of a craft is the work of a lifetime. We might think of trustworthiness as the overarching aim of mastering the craft of psychotherapy.
Recommendations for Clinical Practice
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In advocating a shift in attention from patients’ problems with trust to your trustworthiness as a therapist, I am recommending that you dislodge yourself from the psychotherapy profession’s obsession with perfecting evidence-based treatments for specific disorders. Conscientious practice requires that we therapists be knowledgeable about research but not oppressed by it. As in general medicine, specialization plays a crucial role in developing treatments and generating knowledge that informs generalists. Every therapy requires a treatment and techniques. But the decades-long conflict between researchers and clinicians has been corrosive. The effectiveness of all approaches to psychotherapy hinges on trust and trustworthiness, and the personal qualities of the therapist, including his or her broad personal knowledge, will come first. Specialists are liable to run aground with an exclusive focus on techniques, as I discovered with my first client.
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All therapists must learn theories, treatments, and techniques; however, I recommend prioritizing relationships. Psychotherapy is an interpersonal problem-solving process in which the personal relationship is in the background or foreground to varying degrees. When your relationship with your patient is in the background, as it might be in specialized, symptom-oriented treatments, it is no less important than when it becomes the focus of treatment. Trustworthy psychotherapy of any stripe requires knowledge of the decades-long research on the overriding contribution of common factors that put a premium on the therapist’s interpersonal skill, which will provide the foundation for trust. Alongside the plenitude of research on hundreds of therapy brands, we psychotherapists are indebted to Carl Rogers for identifying empathy, positive regard, and genuineness as cornerstones of therapeutic relationships. We are equally indebted to legions of researchers who have studied the therapeutic alliance, the exemplification of a cooperative relationship on which all trust hinges. From decades of experience working with hospitalized patients suffering from serious mental illness, I am convinced that establishing and maintaining empathy, positive regard, and genuineness—along with a therapeutic alliance that requires them—often is a hard-won achievement. Research on short-term therapies can be misleading in implying that you should quickly establish a good therapeutic relationship such that the treatment can proceed smoothly to a successful conclusion. This means-end thinking is simplistic. Relationship problems contribute substantially to the development of serious mental illness, and illness plays a significant role in relationship problems, including the psychotherapy relationship. In this context, creating a trusting therapeutic relationship comprises much of the work of the therapy, and this creation will be one of its main potential benefits.
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Psychotherapy compels a focus on illness, and more than a century of psychiatry has generated a huge body of pertinent knowledge. You need to start with ameliorating illness, but I recommend that you not stop there. We must have a vision of a healthy life, not only for its own sake but also to prevent recurrence of illness. Every therapist will have an intuitive vision of a good life, developed from his or her personal history and cultural background. I believe that we therapists should reflect on our vision and its associated values. Our values shape our practice, and we should encourage our patients to articulate their values—at the very least, to illuminate and explicate differences in values that could hinder treatment. When we aim to persuade, we should do it consciously and acknowledge our intention. I have said things such has “Now I am campaigning for you to appreciate your kindness more and to direct some of it toward yourself.”
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As I explicate in the rest of this book, I am recommending that we rethink the problem of trusting in psychotherapy, expanding our view from patients’ distrust to the challenges of becoming trustworthy to them. I consider becoming trustworthy in therapy as a patient-by-patient aspiration and, more broadly, as a lifelong project. In a workshop I was conducting about trusting in psychotherapy, a young man just starting out his career anxiously expressed how daunted he was by how much he had to learn and his uncertainty about how to proceed. I sympathized and told him that I hope he continues to feel that way throughout his career. Profound satisfaction is on offer from time to time, but contentment is elusive. Complacency is a sign of trouble: stagnation. We all must keep working at trustworthiness. If you are reading this book, I am now preaching to the choir.
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Trusting in Psychotherapy
Pages: 1 - 49
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Published in print: 22 June 2021
Published online: 5 December 2024
© American Psychiatric Association Publishing
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