George Silberschatz on Psychotherapy Research and Its Discontents

George Silberschatz on Psychotherapy Research and Its Discontents

by David Bullard

Clinician and researcher George Silberschatz, PhD, discusses both the benefits and limitations of psychotherapy research, as well as its misuse by therapists marketing their services.
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What is Empirically Known About Psychotherapy?

David Bullard: Let’s start with a little background information about your work. I first met you through the San Francisco Psychotherapy Research Group—can you talk about your involvement there?
George Silberschatz: Certainly. It was originally called the "Mt. Zion Psychotherapy Research Group,” founded by Joe Weiss who was joined by Hal Sampson, both psychoanalysts, in 1971. They were just starting to publish some research papers and were very active teachers at Mt. Zion Hospital when I began working with them in 1975. Their work together formed the basis of what is now known as Control Mastery Theory.
DB: You’ve been in private practice about thirty-five years and are a clinical professor at UCSF with a multitude of research papers on psychotherapy process and outcome.
GS: My book Transformative Relationships (Routledge, 2005) is on Control Mastery Theory, and my papers are almost evenly divided between research and clinical work, because they are so intertwined and I go from one to the other very easily. ... Continue Reading Interview >>
DB: You are currently the president of the international Society for Psychotherapy Research, which includes chapters in North America, Europe, Latin America, and Australia. Would you talk a bit about the concepts “empirically-validated” and “empirically-supported therapies.” What are your thoughts about what is truly empirically known from psychotherapy research?
GS: Well, I have very mixed feelings about all of it because I don’t think it’s fundamentally based on scientific evidence.
I believe that the term “empirically-validated” is largely used when people are trying to market their specific brand of therapy.
I believe that the term “empirically-validated” is largely used when people are trying to market their specific brand of therapy. You know, “Our empirically-validated therapy is better than everything and everyone else, so if you need therapy, come see us!"

It seems a bit overdone and over-hyped. A lot of people have started saying “evidence-based therapy” instead of “empirically-based,” but what counts as evidence and how is the evidence portrayed? There’s a great deal of subjectivity in that process.
DB: In the early mention of “empirically-validated treatment,” researchers made another distinction between efficacy and effectiveness. Is there such a distinction in the real world versus laboratory research?
GS: It’s a big controversy. The term “efficacy” is used by people who believe that empirical evidence can only come from randomized clinical trials, i.e. in the lab. It has its roots in both medicine and pharmacology in the way drugs are tested and, basically, the proponents of this research paradigm feel that anything else isn’t empirical, isn’t evidence.
Manuals are essentially useless for practicing clinicians.
I wrote an article about this for the Journal of Consulting and Clinical Psychology called “Are results of randomized controlled trials useful to psychotherapists?” It was basically a debate between myself and my co-author, Jackie Persons, who is a cognitive behavioral therapist. She took the position that people should only be practicing empirically validated therapies—by which she meant Random Control Trial-Based Therapies or RCTS—and that it might even be unethical to do anything other than that.
DB: Which implies following a manual that such studies usually use so that the treatment condition is uniform across therapists?
GS: It does often imply following a manual. They punted on this a little bit and said there was some wiggle room for therapists to stray from the manual, but what’s a manual? I took the position that manuals are essentially useless for practicing clinicians.
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Psychotherapy Works

DB: Overall, what would you say has been shown? For example, Consumer Reports did their research on their readers’ reactions to psychotherapy in 1995.
GS: That was a very large survey of psychotherapy effectiveness. I think it had a very useful purpose because it was actually asking the people who were using the service what they thought of it. It was pretty impressive.
DB: That’s refreshing and helpful to hear.
GS: There’s a lot of variability among clinicians, you know? There are a lot of very thoughtful people who think like Jackie, but there are also people that see the limitations of that as a model, especially for psychotherapy.
There is no support for the idea of one therapy being better than another.

The current—and I would say balanced and intelligent—position of the American Psychological Association is that when you really look at the evidence carefully, as they’ve done, there is no support for the idea of one therapy being better than another. But a lot of the proponents of the Randomized Control Trial for psychotherapy use their results to say, “Our results show that our method is better than yours.” That’s led to a rash of people trying to do trials on their new model of therapy. Every time there’s a new therapy, somebody has to do a trial showing that their new therapy is as good or better than some other one. That hasn’t been very productive, in my opinion.
DB: So there have to be quite a substantial number of technical issues within the field of psychotherapy research that we won’t go into today, but I heard Daniel Kahneman, who won a Nobel Prize for Behavioral Economics research, state in a recent interview that the most relevant, reliable outcome measures for a person’s happiness should be based on the report of the person’s friends. In other words, their evaluation would be more valid than anyone else’s. What would you say is the most useful outcome measure for psychotherapy?
GS: Certainly not the therapist’s!
DB: No!
GS: It turns out to be a very complex problem. I respect Kahneman's work very much. He’s a brilliant man. But I’m not sure that I would necessarily agree with him that a friend or significant other in a person’s life would have the best perspective. This is something that has troubled psychotherapy researchers for a long time: How do you measure outcome? Whose perspective do you rely on? There are plenty of people who feel the therapist has the best position. There are other people who feel that the patient is in the best position. There are yet other people who—
DB: How about the patient’s mother?
GS: She may not be in the best position either! Because someone like a mother or a spouse may have a particular vested interest. But it’s a very thorny problem in psychotherapy research and I don’t think anyone’s come up with a definitive answer yet. I think we tend to use multiple perspectives now but that creates its own particular difficulties as well.
DB: You have studied both outcome and process-oriented research. Overall, hasn’t it been shown through meta analyses of lots and lots of studies that psychotherapy works for the vast majority of people who undertake it?
GS: Yes.
DB: And other studies of process show the elements that seemed to have the most impact within a psychotherapy relationship.
GS: Well, you’re quite right that there’s evidence available now that shows unequivocally that psychotherapy works. There should be no more questions about that in anyone’s mind.
Evidence available now shows unequivocally that psychotherapy works. There should be no more questions about that in anyone’s mind....The issue of what it is about therapy that is causing it to work is still up for a lot of debate.
It definitely does work. What that means, concretely, is that a person who is having any one of a variety of psychological, emotional or behavioral kinds of problems will do far better getting psychotherapy than not. The issue of what it is about therapy that is causing it to work is still up for a lot of debate. And, of course, every school of psychotherapy, every brand, has their own particular perspective on that.

One thing that people do generally agree upon is that the therapeutic relationship, the nature of that relationship that some people call the “therapeutic alliance,” is a critical factor. Other people say the relationship is a necessary, but not sufficient, condition, but what is it about the relationship? If you’re a clinician, and you’re about to meet a new patient, the research doesn’t really tell you what you might do to enhance that relationship. What are the things that are involved? What are the steps involved in creating these productive therapeutic relationships?
DB: Versus looking up in the manual to find out which antibiotic to give for which infection?
GS: Yes, but even with antibiotics, it turns out that a lot more of that is art and trial-and-error than we are led to believe. It’s not quite as cut-and-dried and as narrowly evidence-based. People try one thing and that may work on half the patients. But it doesn’t work on the other half, and then you have to start experimenting with tweaking it.
DB: I guess we’d like to pretend that we live in a world of certainty.
GS: Yes. There is something inherently reassuring about that. But it’s also quite elusive, in my opinion.
DB: I’m reminded of an old saying: “There is no Zen, only Zen teachers.” In a way, there is no “psychotherapy.” It’s only each unique interaction between two people (or three people if it’s couples therapy).
GS: I think that framing it this way goes back to a very old argument in psychology. The controversy about nomothetic versus idiographic principles. Ideographic being very individualized kind of principles, and nomothetic applying to large general populations. And in psychotherapy, my own view of it, both clinically and per research, is that it is very individualized.

So what’s going to work well for one person is not going to necessarily work well for another.
Therapy has to be tailored to the particular needs and goals of the patient we’re working with.
Therapy has to be tailored to the particular needs and goals of the patient we’re working with. But, having said that, I also think that there are some general principles, and here is a good example of one: If therapy is tailored to the needs of a particular person, all other things being equal, it will be more effective and more successful.
DB: Your background and your extensive work with Control-Mastery Theory, developed by Joe Weiss and Hal Sampson, is all about that.
GS: Yes. Very much so. It’s one of the things that really drew me to their work. It really takes into account the particulars of a person, the nature of their particular problems, what their particular history is, and how the therapy can address that in a very individualized way.
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"We Forgot to Ask the Patient!"

DB: What’s your opinion on getting regular feedback from clients? The research that I’ve seen, both for individual therapy and couples therapy, seems to be clear that having clients give written feedback after every session improved either the alliance or the outcome. Should therapists be encouraged to incorporate that more into their clinical work?
GS: It’s a very good question, and it’s an area that is really taking off like wildfire right now, not just in psychotherapy, but in the field of healthcare generally. One of the biggest initiatives in many, many years, at the National Institutes of Health, is what they call “Patient-Centered Outcomes Research.” A lot of research in healthcare, for decades actually, was really just based on what lab tests showed, or what a physician concluded. Nobody bothered to get the patient’s perspective, and suddenly people are saying, “Oh, my God, we forgot to ask the patient!”

So now there’s this huge catch-up game going on in terms of trying to get the patient’s point of view. In psychotherapy research, we’ve certainly taken the patient’s view into account a lot, but what is newer in psychotherapy is this point that you’re raising about feedback, and getting patients’ feedback after every session. People have tended to use symptom-based measures, so patients fill out a form at the end of each session to see how they rate the severity of various symptom profiles.

I think that getting the patient’s feedback is very useful, but I’m not particularly impressed with symptomatic measures. I think there are probably more important things that one could find out from the patient after a session. What did they find useful? How did they feel the therapist was responding to them? That’s useful information for therapists to know, and historically we just relied on our own impressions to get that kind of information.
Sometimes we’re right; sometimes we’re wrong, and we often don’t know which is which.
Sometimes we’re right; sometimes we’re wrong, and we often don’t know which is which. Having the patient be the arbiter of that information is very valuable.

Even without written feedback, one would hope that an experienced practitioner would draw out the patient’s feelings and perceptions if he’s seeing some kind of transference to what a therapist has said or done. We hope that that would be an integral part of the work.
DB: Sure.
GS: Some therapists, of course, explicitly ask patients at the end of or at some point in the session, “Well, how do you feel things are going today?” Or, “How do you feel you’re doing?” Or, “How are things with us?” That’s a useful thing to do, but the people that are more into systematic feedback would say that you may get more reliable data if the patient is outside of the session, sitting, thinking about the influence of the therapist. You may get a more complete picture of the patient’s experience that way, instead of—what’s that old term in research?—the “socially desirable” answer.
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"What Exactly Does 'Cured' Mean, Anyway?"

DB: Let’s switch back to the marketing aspect of “evidence-based therapies.” I recently came across a practitioner’s website where he claimed that his particular brand of marital therapy has proven to be effective with 90% of his couples and 70% were “cured.” What are your thoughts about that?
GS: It strikes me as primarily marketing. It’s hard for me to wrap my mind around numbers like that. What exactly does “cured” mean, anyway?
DB: Talk about the medical model! As if the people came in limping and left skipping merrily along.
GS: There’s plenty of evidence that therapy, including couples therapy, is effective. It works. But there’s no evidence whatsoever to support the idea that one particular brand is systematically better than another. There just isn’t evidence for that. People make all kinds of claims, but it just isn’t supported when you look at it on the broadest possible level.
DB: I found a couple of articles through the American Psychologist with tables about empirically validated therapies. One broad grouping is “well-established treatments.” And then they have “probably efficacious treatments.” I’m sure you’ve seen all of that.
GS: Yeah, absolutely.
DB: And someone cited 420 different defined psychotherapies. Do you think those are also marketing attempts to differentiate themselves from the rest?
GS: Yes, I think it is primarily marketing. I mean, there just can’t be 420 fundamentally different ways of doing this work. It flies in the face of common sense. I see it as what somebody called the “narcissism of small differences.” People have variations on cognitive therapy, to take a few examples. Albert Ellis, “Rational-Emotive Therapy.” You have Aaron Beck’s “Cognitive Therapy.” You have Jeff Young’s “Schema Therapy.”
There just can’t be 420 fundamentally different ways of doing this work. It flies in the face of common sense. I see it as what somebody called the “narcissism of small differences.”

And then there are probably 20 other variations of it. Well, are they really all that different? I don’t think so. I think it’s just people wanting to create a brand rather than looking for commonalities. They’re looking for, “this is my way,” so that they can develop empires and training institutes and all that.
DB: I’ve talked to a number of colleagues, a few of whom I guess may be possibly nearing retirement, and they look back over the years and wonder, “How did I do? How did it all go?” Arnold Lazarus, years ago, did some follow-up with as many of his patients as he could. Could you comment on how he did that, or your knowledge of that?
GS: I don’t know the specifics of Lazarus’ work on that, but I do know therapists who do this routinely. I’ve always had a lot of fascination and admiration for it, where a therapist will, after a number of years, get in touch with their patients and ask them to come back and to check in and to see how they’re doing. This is, obviously, without charging a fee. It’s just the therapist wanting feedback. Lou Breger wrote a book recently called Psychotherapy: Lives Intersecting in which he describes his experience contacting a lot of his former patients, and asking them how they’ve done. I think more of us should do it, probably.
DB: There are ways to do it, obviously, that ensure ethical reconnection with past patients.
GS: Yes. One has to be sensitive to respect their privacy. I mean Lou Breger got permission from all of his patients and any identifying data were disguised in his book. But even if one isn’t writing about it, just for one’s own edification, systematically getting a patient’s point of view several years after the end of therapy—what they felt about it, whether it was helpful or not helpful—could help sharpen us as clinicians.
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We Are All Skinner's Pigeons

DB: Do you feel your clinical work with people is impacted by research results and, if so, to what degree? Or are you more impacted by what has happened in the session? One person pointed out to me quite a while ago, that in a sense, we therapists may be similar to Skinner’s pigeons—we get reinforced to do the things that work for us with our individual clients or couples. Research and theory can, perhaps, clarify and codify what we are doing or should do, but meanwhile, we’ve been getting these experiences with people about what works and doesn’t work. Do you have a sense of whether your own direct experience of doing therapy is most influential, versus reading research results?
GS: I’d say that my own work has been more influenced by my patients’ feedback and from teaching and observing what other therapists are doing in their work and how that’s going. In that case, I have the luxury of not being in the room at that point so I can think more broadly about what’s happening or not happening. I would say that those experiences, along with my own supervision—I’ve had therapy supervision for many, many years by really good people—have probably shaped my work the most.

There are some things from research that have also affected me. In my early training, which was largely psychoanalytic in the 70’s, the role of interpretation, particularly transference interpretation, as a primary mutative factor, was thought to be the primary effective ingredient of psychotherapy. My colleagues and I did some research on that and found, along with others, that there was no evidence that transference interpretations were especially powerful.
My colleagues and I did some research ... and found, along with others, that there was no evidence that transference interpretations were especially powerful.

So that certainly led me to rethink everything. I thought, “Wait a minute. All the stuff that we’ve been learning from very senior psychoanalysts—there isn’t really any evidence supporting it other than the fact that they say so?” That really led me to question the role of interpretation in psychotherapy.
DB: Is that close to the idea that information—insight—can be imparted that will change people versus people having an experience that changes them?
GS: That’s exactly right. There’s a very gifted psychoanalyst, Frieda Fromm-Reichman, who said patients don’t come for insight; they come for experience. So this view has been around for a while, particularly in the so-called interpersonal school of psychoanalysis. I think that more often than not, people do learn from their experiences.

Having said that, I also want to say that in terms of my commitment to individualizing psychotherapy, it is true that there clearly are people who do learn a lot from new information, so I don’t privilege one or another. I don’t privilege the idea that there’s a particular technique that is across the board better than others. We might even say that for some people, having a new insight, a new thought about themselves or their lives or their childhood or current process, gives them a new experience.
DB: Yes, it can.
GS: Maybe more compassion for themselves.
DB: It could work both ways. It can work that the insight gives them new experiences. It can also work that new experiences opens them up to new insights.
GS: I would say it really does work both ways. And there’s no way to know in advance which it’s going to be for any given individual.
DB: What are your thoughts more generally about the role of research in a practitioner’s life?
Unfortunately research hasn’t given clinicians and practitioners a lot that they can use.
Unfortunately research hasn’t given clinicians and practitioners a lot that they can use. That is changing and will continue to change in a positive way, but the whole emphasis on the Randomized-Control Trials and so on has not helped clinicians much in my opinion. Other people have different views about this, obviously.

I think what can begin to help clinicians more is the very consistent research finding that “therapist effects” trump treatment effects. In other words, if there are therapists doing a trial of three different therapies, it turns out that there are particular therapists in all three of those conditions who are actually better than their peers.
DB: Those must include what some have referred to as “non-specific treatment effects.”
GS: And those effects are bigger than the particulars of the therapy that’s being practiced. To me, that’s a really interesting finding. And the question that it begs is, well, what are those therapists doing? Let’s figure that out. And, if we can figure out more about that, we could try to train other people to do that or try to incorporate more of that in our own work.
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"He Was a Wise Dude, That Buddha"

DB: The final area I’d like to discuss with you is your own interest and involvement in Buddhist concepts. You’ve done very well-received seminars and workshops with Steve Weintraub, a Zen priest and psychotherapist, on Buddhism and psychotherapy. Is there anything that you would like to say about that?
GS: Overall, Buddhism, for me, as well as just the experience doing psychotherapy, has taught me that much in human life seems to get better when you can have more self-compassion. I’ve been interested in Buddhist thought for a very, very long time. My interest in it probably dates back to when I was studying psychology as an undergraduate. I was really interested in Freud. I was interested in Carl Rogers. I was interested in the Human Potential Movement.

Then I had this kind of—I don’t know what to call it—like an insight. I thought, “Wait a minute. People have been thinking about these things way before Freud, way before Rogers or Maslow; there’s a history to this. And it’s a very, very old and long one.” I would say that
Buddhist thinkers have been paying attention to the nature of mind and suffering for longer than just about anybody else.
Buddhist thinkers have been paying attention to the nature of mind and suffering for longer than just about anybody else. They’ve had a lot of valuable insights into what causes people to suffer, and how people’s suffering can be alleviated and reduced and so on. So at that broad level, I think Buddhism has a lot to teach us about just basic human psychology, and particularly the nature of suffering and what causes people’s suffering.

It’s different, in my opinion, from organized religions, in the sense that it doesn’t say one’s salvation will come through this or that route. I would say it’s a very broad model. It allows people to apply the teachings in their own lives in their own way. It doesn’t really require going to church or synagogue every week or every month or that kind of thing. But it does give certain tools that people can use in a very reliable and useful way.
DB: I’ve seen a commentary attributed to the Buddha, where he sounded like an empirically-based fellow. He essentially said, “Don’t believe anything I’ve told you. Try these things out for yourself. And if they work for you, great. If they don’t, go onto something else.”
GS: Yeah. I think that’s one of the things that has contributed to Buddhism gaining enormous popularity in the West right now. We have something that fits very well with the kind of individualized and democratic mindset that we can learn things by seeing what works for us. There is a lot of wisdom in that. He was a wise dude, that Buddha.
DB: They’ve updated it. I’ve run across some people who are espousing “Open-Sourced Buddhism,” that we are free to choose from those schools of Buddhist thought, from the very cognitive-based wisdom of Tibetan Buddhism to the no-thought idea of Zen.
GS: I love the idea, and would love to see more of that open-source thinking applied to psychotherapy. One of the things that we have right now in therapy is the equivalent of proprietary systems, where people develop one of those 420 brands of therapy, and then you just have to get in and do it that way. As opposed to an open-source model, which is people getting in there and using it for their own purposes and contributing to it, growing it in their ways—which is what’s happened to Buddhism. People are growing in all kinds of ways in the West, and I’d love to see more of that actually happen in psychotherapy.
DB: Supposedly a graduate student went to Jung one time and asked, “How do I become the best therapist I possibly can?” And he replied, “Go to the library, read everything good that’s been written about the art and science of psychotherapy, and then forget it all before you peer into the human soul.”

Well, thank you. I really, really appreciate having had this time with you.
GS: Thank you.

© 2013 David Bullard
CE Test
George SilberschatzGeorge Silberschatz, PhD, is a Clinical Professor in Psychiatry at the University of California San Francisco School of Medicine (UCSF). Internationally recognized for his psychotherapy research, Dr. Silberschatz has given over 300 presentations at professional meetings and workshops throughout the United States, Canada, and Europe and has published some 60 papers in various professional journals and books. He is currently the international president of the Society for Psychotherapy Research. His book on psychotherapy, Transformative Relationships, was published by Routledge in January 2005. He currently divides his time between a private practice in San Francisco, teaching and supervising psychotherapy, and writing clinical and research papers.
David Bullard, Ph.D., David has had a private practice of individual psychotherapy and couples therapy in San Francisco since 1976. He is a clinical professor in departments of medicine and psychiatry and a member of the professional advisory group of Spiritual Care Services at the University of California, San Francisco, and is a consultant for the Symptom Management Service (outpatient palliative care) at UCSF’s Helen Diller Family Cancer Center. His latest professional publication is the chapter “Sexual Problems” (co-authored with the late Harvey Caplan, M.D., and with Christine Derzko, M.D.) in Behavioral Medicine: A Guide for Clinical Practice, 4th edition (2014; McGraw-Hill). He has previously published interviews for with Allan Schore, Ph.D.; Bessel van der Kolk, M.D.; Mark Epstein, M.D.; Ida Gorbis, Ph.D.; George Silberschatz, Ph.D.; and Lonnie Barbach, Ph.D.; and also has written about conversations with Tibetan Buddhist scholar Robert Thurman, Ph.D.
Thanks, David, for sending the interview you did with George. You both did a fantastic job. "Very insightful." I liked the way the interviewer and interviewee occasionally exchanged roles. David, you are a gifted interviewer, and George is a fountain of information and wisdom. What a delicious treat you both have provided us!
Stan Lipsitz, Ph.D.
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CE credits: 1
Learning objectives:
  • Describe Silberchatz's theory about the efficacy of psychotherapy research.
  • Delineate the difference between "evidence-based" and "empirically-validated" therapies.
  • Understand the importance of patient feedback in psychotherapy.
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