I write this post as a clinical psychologist who is very concerned about my profession. Psychotherapy has, in my opinion, become of shell of its former self. Complex clinical decision-making and case formulation have been replaced by mechanical views of the therapy process. Clinical manuals rule the treatment approaches many clinicians take. These manuals provide a “paint-by-numbers” approach—a term first used by W.H. Silverman in 1996, where specific steps guide each treatment decision. There is no room for variation as each case is treated the same as every other case with a similar diagnosis. Licensed professionals are not expected to incorporate their own insights and understandings but are instead expected to just follow each step towards a predetermined goal, which is similarly lacking in any individuality.
Even the heavily-used phrase “empirically-supported treatments” often seems devoid of any real meaning. It is supposed to reflect an understanding of clinical approaches emphasizing the scientific method. But this approach often utilizes science only in the most superficial ways.
Here’s how a typical approach to “empirically-supported treatment” works. Hundreds or even thousands of individuals who all meet the same diagnostic criteria are grouped together and specific treatment steps are applied. Members of each group are then subjected to the same sets of steps with little room for variability or individuality. There is no focus on why problems occur. Nor is there a focus on why treatment steps work. There is just a focus on finding steps that work for the largest groups and sharing those specific steps with any many clinicians as possible.
This is all much the same way that medicine is practiced. Physicians prescribe medications without necessarily knowing exactly why they work. There may be some recollection of biochemistry from medical school, but it is not necessary that physicians recall those details while following what the PDR says to prescribe.
So, implementing treatments without knowing exactly why they work is not in and of itself a problem. It is just that psychotherapy is supposed to be different. Psychotherapy is supposed to emphasize a full understanding of why people act the way they do. Freud emphasized defense mechanisms, Harlow focused on emotional attachment and Skinner highlighted reinforcement. All the most prominent names in clinical psychology, at least up until this century, recognized understanding problems to be as important as understanding specific treatment approaches.
Science used to be incorporated throughout psychotherapy. There were scientific studies of personality traits contributing to depression, anxiety, and other disorders. True scientific research guided understanding of how behaviors develop and what factors maintain them. Conflicts occurring between individuals as well as those within individuals were researched in very detailed ways. All of these issues continue to be studied but are given much less emphasis in modern clinical psychology, compared to the step-by-step therapy approaches.
Basic psychological research is the approach used for studying psychological processes. This type of research used to be emphasized much more than it is now for guiding psychotherapy. In fact, it used to be emphasized as much as clinical research. Laboratory and observational studies were used to more fully understand factors contributing to clinical issues. Basic psychological research was understood to more fully apply the scientific method than could ever be the case in clinical settings.
There are many places where I’ve seen the weakness of clinicians who have limited understanding of basic research findings. One such example is when I supervise clinical staff on behavior therapy. There is a vast amount of research, spanning decades and involving human and nonhuman subjects, showing many complex ways that behavioral constructs such as reinforcement schedules, extinction, fading and response strength function and interact with each other. But many clinicians are only familiar with the basic aspects of reinforcers increasing target behaviors. As a result, they wind up with behavioral interventions that are very, very simplistic and then they and their clients wonder why those plans aren’t working.
This is not the sort of problem that can be addressed with research only investigating general clinical interventions and generic outcomes. What is required is an understanding of the complexity of how behavioral constructs work and all the important factors involved. Clinical research just doesn’t address that. Rigid application of the scientific method addressing targeted research questions, with multiple opportunities to get findings out to clinicians “out in the field”, is what’s needed. Research funding in the social sciences is moving away from that. Hopefully, this can change.
1) Silverman, W. H. (1996). Cookbooks, manuals, and paint-by-numbers: Psychotherapy in the 90's. Psychotherapy: Theory, Research, Practice, Training, 33(2), 207.
File under: The Art of Psychotherapy, Musings and Reflections
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Even the heavily-used phrase “empirically-supported treatments” often seems devoid of any real meaning. It is supposed to reflect an understanding of clinical approaches emphasizing the scientific method. But this approach often utilizes science only in the most superficial ways.
Here’s how a typical approach to “empirically-supported treatment” works. Hundreds or even thousands of individuals who all meet the same diagnostic criteria are grouped together and specific treatment steps are applied. Members of each group are then subjected to the same sets of steps with little room for variability or individuality. There is no focus on why problems occur. Nor is there a focus on why treatment steps work. There is just a focus on finding steps that work for the largest groups and sharing those specific steps with any many clinicians as possible.
This is all much the same way that medicine is practiced. Physicians prescribe medications without necessarily knowing exactly why they work. There may be some recollection of biochemistry from medical school, but it is not necessary that physicians recall those details while following what the PDR says to prescribe.
So, implementing treatments without knowing exactly why they work is not in and of itself a problem. It is just that psychotherapy is supposed to be different. Psychotherapy is supposed to emphasize a full understanding of why people act the way they do. Freud emphasized defense mechanisms, Harlow focused on emotional attachment and Skinner highlighted reinforcement. All the most prominent names in clinical psychology, at least up until this century, recognized understanding problems to be as important as understanding specific treatment approaches.
Science used to be incorporated throughout psychotherapy. There were scientific studies of personality traits contributing to depression, anxiety, and other disorders. True scientific research guided understanding of how behaviors develop and what factors maintain them. Conflicts occurring between individuals as well as those within individuals were researched in very detailed ways. All of these issues continue to be studied but are given much less emphasis in modern clinical psychology, compared to the step-by-step therapy approaches.
Basic psychological research is the approach used for studying psychological processes. This type of research used to be emphasized much more than it is now for guiding psychotherapy. In fact, it used to be emphasized as much as clinical research. Laboratory and observational studies were used to more fully understand factors contributing to clinical issues. Basic psychological research was understood to more fully apply the scientific method than could ever be the case in clinical settings.
There are many places where I’ve seen the weakness of clinicians who have limited understanding of basic research findings. One such example is when I supervise clinical staff on behavior therapy. There is a vast amount of research, spanning decades and involving human and nonhuman subjects, showing many complex ways that behavioral constructs such as reinforcement schedules, extinction, fading and response strength function and interact with each other. But many clinicians are only familiar with the basic aspects of reinforcers increasing target behaviors. As a result, they wind up with behavioral interventions that are very, very simplistic and then they and their clients wonder why those plans aren’t working.
This is not the sort of problem that can be addressed with research only investigating general clinical interventions and generic outcomes. What is required is an understanding of the complexity of how behavioral constructs work and all the important factors involved. Clinical research just doesn’t address that. Rigid application of the scientific method addressing targeted research questions, with multiple opportunities to get findings out to clinicians “out in the field”, is what’s needed. Research funding in the social sciences is moving away from that. Hopefully, this can change.
1) Silverman, W. H. (1996). Cookbooks, manuals, and paint-by-numbers: Psychotherapy in the 90's. Psychotherapy: Theory, Research, Practice, Training, 33(2), 207.
File under: The Art of Psychotherapy, Musings and Reflections