Larry Beutler on Science and Psychotherapy

Larry Beutler on Science and Psychotherapy

by Hui Qi Tong
Larry Beutler discusses how to incorporate scientific findings into psychotherapy practice and teaching, and what horse training has to do with any of this.


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The Making of a Psychologist

Hui Qi Tong: Good morning, Larry.
Larry Beutler: Good morning.
HT: So I've known you in different capacities for a couple of years, and I have to confess that it's always been on my mind over these years that one day I might have the opportunity to just sit across from you and interview you.
LB: Well, I'm glad to get a chance, myself. It's nice to have you here.
HT: I'm always kind of intrigued with people's passions--their choice of profession. How did you come to choose to be a psychologist?
LB: That's a good question. Subjectively, I'm not sure I chose. I think the profession kind of chose me. My first year in college, I had probably four different majors. I started out in chemistry because my cousin was in chemistry. And then in the middle of the quarter I think I switched to physics. I went through math. By my second year I think I'd been in art, I'd been in social science, I'd been in sociology, I'd been in pre-law. But I transferred from a junior college to a university, and on a whim, I'd taken one psychology course and I'd really enjoyed it, and they asked for my intended major and I wrote down "psychology." And I've never looked back.

But I'm sure that it's more complex than that. I think there are other some other hidden issues. I had struggled for a long time, as most adolescents do, trying to find a place for myself, and....

HT: To establish your identity.
LB: And a lot of my identity was built in regard to my family's very conservative values. And part of their conservative religious values put them at odds with what I came to be learning in high school and college, in particular, around the role of service. My family's values emphasized the role of service, but only within the confines of a religious organization. And it really had a very hierarchical kind of structure. And I became very concerned with what it did to disenfranchise certain people--people who were outsiders, people who by virtue of their skin color, by virtue of their ethnic background, by virtue of their gender, were given a different role within my family's value structure. And I struggled with that for many years and ultimately made some very significant changes. quote[:I made specific decisions about wanting to build into my life a view of people that was infused with more equality than I had seen.] I don't mean to say that my family wasn't respectful and interested in people's assets, but they regarded people only based on their religious beliefs, and infused in those religious beliefs were a lot of attitudes about gender and race. Within their religious view, for example, people whose skin was darker colored than Caucasians came from a place prior to their birth that was less righteous than those of us with white skin. And that was a real troubling aspect for me as I came into my early twenties, and became an organizing theme for what essentially became a break with my family and a break with my traditions.
HT: Have you had any opportunity to voice your own opinions within your family?
LB: Oh yeah, I did What it meant was that nobody in my family would talk to me for a number of years!
HT: That's hard.
LB: When I was going through this struggle, we had strong words. I was not slow to voice my objections. And I did so in a very clumsy, awkward and hostile way. And what it did was disenfranchise me from my family, my sister, my father, and all my relatives that I'd been raised with. And some of those relationships have survived, some have healed at least partially, and some never healed. So I would have to say it was in some ways costly, but it was also freeing. I did become very much my own person in that regard, in how I set my values. But by the same token, what I set as a value, to live what I considered to be a good life, was very different from what I'd been raised with, and there have been periods in my life where I've had to struggle with, and really make sure I was doing what I had vowed myself to do. And you know, I haven't always been successful in that. I find little pieces of bigotry and rigidity and other kinds of things hidden in my persona that I have to expunge from time to time. It has been an organizing theme for me.
HT: What was your family's religion?
LB: Our religion was Mormon. And the reason I guess that this comes up right now is I've just been in a conversation with a childhood friend that I have resurrected a relationship with. We haven't talked to each other for 50 years. But over the past year, we've developed a friendship again. And he has had a lot of similar experiences that I had in regard to family struggle, and now I'm in contact with his brother, and I've just gone through a week of revisiting some of these old issues. And resurrecting some of the feelings that occurred to me back when I was going through this in my twenties and thirties. So it's very raw to me right now. But I think that it was very pointedly involved in my decision, happenstantial as it might have been, to get into the helping fields, and ultimately to become a clinical scientist and practitioner in psychotherapy.
HT: So that's really profound, your experience during adolescence and young adulthood, how you moved away from the old frame of view and broke some bonds to free yourself to establish your own identity. You mentioned that before you entered psychology, you were exposed to math, chemistry, physics. I also believe that no experience is wasted.
LB: Oh, no, I enjoyed it.
HT: And you're such a hardcore scientist in the field of psychology. I just wonder whether the experience of being immersed in basic science had an impact on your research in psychology.
LB: I think so. I think I gained some appreciation for science in that process, although my original aims in psychology were to be a private practitioner. I didn't make the decision to be a scientist until I was well into my doctoral studies. But it occurs that that is a theme in my life: I wind up making decisions that, it feels to me, are really not made decisively. But as I look at my life it's almost as if I had planned it from the beginning.
HT: That's a wonderful feeling.
LB: It's a curious phenomenon to observe that one does make something of their life, and sometimes their brain is the last part of them to know.

The Challenge of Training Psychologists

HT: You mentioned you started out wanting to be a practitioner, then later on became a researcher, a scientist-practitioner. I wonder--at our school (Palo Alto University) our training model is more practitioner-scientist--if you were to design a training program, how would you design it?
LB: Well, that too is a good point, because I struggle with that still. I struggle with it now as I teach my Introduction to Psychotherapy class, because I designed that as I have thought for years would be the best way to teach people how to be good psychotherapists. But I'm finding now that I may be wrong, that I have to relook at how I develop the steps to becoming a good scientist-practitioner, practitioner-scientist.

I wound up moving from being a clinical researcher with, as most psychologists want, a practice on the side. I've always had a practice, and sometimes it's been a very big part of my life, but other times it has not been. But always there since receiving my PhD, has been the clinical scientist. My practitioner world has been taking what I find in the laboratory and then trying it out. And there have been people who have talked about their research--good scientists like Hans Strupp, for example. He's a remarkable man. But he's always said that his research findings, his science, really never had any influence on his practice. And see, I find just the opposite--what I found in my research had a very direct impact on it. And that being the case, I see that what has occurred as I have thought about the third role, which is education, that I have changed a lot in how I think the concepts need to be given or provided for students. And I'm still changing, and I'm not certain about that right now. Because I'd say what I have been doing the past three or four years isn't working as well as I'd hoped it would.
HT: What have you been doing the past three years?
LB: I've been trying to teach the students from the beginning what the core basic concepts are in psychotherapy, independent of the theoretical model they apply. The core basic principles, the most fundamental ways of looking at an individual and constructing the interaction that will have a beneficial effect. This is what I've derived from my research, looking at others and so forth. The fundamental core principles of psychotherapy.
HT: Do you mean the principles of change or...
LB: The principles of change, the principles of how one person can interact in a closed environment with another person to facilitate change. And I put a lot of stock in those principles. And the more I find out about them, the more I find that there are more principles, but there are some really good ones. I just wish I could articulate them better. But I have been operating on the assumption that if I taught them the basic principles first, and then taught them their theoretical models, that then they would be better practitioners. But this is just the opposite of what I did for years at the University of California: we would teach the theoretical models first and then teach them how to integrate concepts out of those models and principles.
HT: So now you're adopting an approach that is broader to start with--just lay the foundation, then later on students will study the specific models.
LB: That's the idea. And it sounds good. But it's not working. It's really not working.
HT: How can you tell it's not working?
LB: My students tell me. I mean, I am going through a period where students, I am finding, are very resistant to the methods that I am applying. And so it makes me want to return to some of the ones that worked before, and to redo the educational process. So in answer to your question, I don't have a handle on how to go about teaching people at this point. I have little glimpses of how to teach people. The real problem that you have in trying to teach people psychotherapy is you can't just teach them about it--you have to expose them to it. And in the beginning processes, that is a very tender, fragile kind of interaction, to teach people to interact with a client. Because the therapist is afraid, the client is afraid, and bad things might happen. Good things might happen, and most of the time they do. But bad things might happen. So one has to be careful in that initial interaction. I haven't found a way to do that in a way that students feel safe enough to try it.

I don't like the way that psychotherapy is conventionally taught. I don't think it works well. I think out of it we have produced one third of therapists who are ineffective at best and maybe harmful. That's not a good track record. We have an article that just came out, for example, in one of the APS [American Psychological Society] journals from some old colleagues of mine,1
that most psychologists simply don't practice anything based upon any scientific evidence whatsoever.
that most psychologists simply don't practice anything based upon any scientific evidence whatsoever. And we know that. We've known that for years. And what they propose is that we begin to make our training programs reflect specifically how well students are able to incorporate scientific findings into what they do. I think it's important. But then, just this morning I was interacting, I'm a member of APA Council and I was interacting with people on the Web about this very article. And one of the very strong themes in that is, "These people are all wrong. Science doesn't matter to clinical practice." And these are very senior people. Some of the former APA presidents and leaders are saying this, that science doesn't really matter to practice. These people are all wrong.

Making Science Matter

HT: You have a paper just published this year about making science matter and redefining psychotherapy. What I see that's interesting is that bidirectional communication is disconnected. Some clinicians do whatever they want, and disregard what scientific evidence is there. And some researchers actually don't pay attention to what's really going on in the room.
LB: They don't. They don't.
HT: They come up with narrow, rigid focuses of the scientific inquiry, as well as the way they design their research.
LB: That's very true. We have, I think, in the course of our experience as a budding science, defined ourselves almost out of… not out of existence, but out of value. We try to adopt, in the psychotherapy field, a model of research that was being used very successfully in psychopharmacology, was being used somewhat less successfully in medicine, but was highly advocated and highly regarded. And it was a model that to many people looked really good. It's the medical analogy that you consider the treatment to be like aspirin: we need to know the ingredients of it, and the person who gives it shouldn't matter. So we give cognitive therapy disembodied from the therapist. And we studied in a disembodied fashion. Now people are giving lip service, finally, to the inappropriateness of that, but they haven't changed the method. They still rely upon that narrow method that says we will train people to follow a prescription, we will train them to do it so it doesn't matter who is delivering it. And then we will study the outcome.

And the one thing that these people are wrong about is they make a big case out of the fact that they have discovered that cognitive therapy worked well with all of these groups. Now, they're right. But what they don't say is that they've discovered that cognitive therapy is better than something else. Because we haven't discovered that. What we've discovered is cognitive therapy works. But people hear the implication that it works better, and therefore we should be doing it. But that's only because we have in our research model excluded characteristics of the therapists, nondiagnostic characteristics of the patient, qualities of the context, and certainly qualities of the relationship. And so the paper you're talking about is one in which I try to make the argument that
psychotherapy is not just what the therapist does. It is, in fact, who the therapist is, how the therapist interacts, who the client is, how they interact, and the nature of the relationship.
psychotherapy is not just what the therapist does. It is, in fact, who the therapist is, how the therapist interacts, who the client is, how they interact, and the nature of the relationship. And all of those components can be scientifically studied. But they can't be studied using the research designs that we're currently using. Interestingly, out of that, I've gotten an invitation to present a paper at the SPR conference in June at Asilomar.
HT: What's the SPR?
LB: It's the Society for Psychotherapy Research, an international society. I've been president of it. But it was the place in which Gerald Klerman, who was head of the National Institute of Mental Health, made his first pronouncement that we were going to study psychotherapy as if it were aspirin, and initiate the randomized clinical trials model for psychotherapy research. And at that point we began forgetting about therapists and patients and relationships.
HT: That reminds me of evidence-based practice in psychology--it's really parallel with evidence-based practice in medicine.
LB: Well, that's what they try to make it.
HT: Tell me about your opinion of the EBPP [evidence based practice in psychology] movement. There are so many different terms coming out of that, and now there's also research-informed practice. I'm a bit confused about all these forms.
LB: I'm confused too. I strongly believe that practice should be research based, and should certainly be more than research informed. "Research informed" is where the American Psychological Association has now taken this with their task force a few years ago. This was discussed just the other day in the council exchange that I was talking about a moment ago, where James Bray, who is currently the president of APA, tried to make the case that psychotherapy is not research based, and should not be. According to him, it should be based upon research knowledge, plus patient values, plus the personal impressions, feelings and judgment of the therapist. And that to me is a scary thought, but that's where we are in psychology.

It's the one thing that makes this whole thing into a soup rather than a science, because it says there are three equivalent ways of knowing something is true: one is through patient values, one is through the observations and judgment of the clinician, and the third is through science, and they are to be equal as they go into this soup. Well, to me that makes a soup that has no character. Because if we don't keep the research base--not just research informed, but research grounded--we are back to the point in our history that anything goes as long as you're sincere. The patient values guide us. Those values may be quite disturbing and distorted. Certainly we know that therapists' judgment is often very poor. If one third of therapists produce more patients that get worse than get better, well, I'm not sure I want to trust my children to those therapists. And that means that we need to do something to improve their judgment, and I don't know any better way to do it than through scientific grounding.
HT: It seems to me that all of these three components--the patient's values and preferences, the clinician's wisdom or experience, as well as the scientific evidence-- should be integrated and tested.
LB: They should be integrated. If we could adopt research, plans, programs and methods that incorporated the investigation of how patient values affect clinical judgment and treatment procedures that would be psychotherapy. But as long as we are conceptualizing it as separate, it will stay separate and it will stay ineffective. The common finding is still that all therapies are the same. It doesn't matter too much whether it's therapy as usual or whether it's a therapy constructed out of the theoretical research model or what. They're all pretty much the same as long as all you do is study them in a disembodied way, separate and independent of the patient's values and of the therapist's judgment, experience, background, etc.
HT: That reminds me of the Dodo bird verdict2, that everything works.
LB: It is a Dodo bird verdict. All have won and all must have prizes. Everybody wins. The problem is also that everybody loses.
HT: Yeah. So if in the near future there would be a new research design which is not as narrow, incorporates every factor that is important, relevant...
LB: I'm cautiously optimistic. I want to be alive when it happens.
HT: But you're doing it now.
LB: Well, I have tried very hard to make it happen. If I have a mission in the world, this is the mission I would like to accomplish.
HT: Can you state your mission so we capture it here clearly?
LB: To redefine what we are studying in psychotherapy, to be more inclusive rather than exclusive, to be inclusive of the common factors, to be inclusive of the therapist factors, patient factors, etc., that are not bound within these narrow definitions of diagnosis and treatment model. Now, it seems periodically that we have made some headway in doing that. People are interested in this paper I published3, they're citing it and so forth. But it's not the one that's getting on the front page of the New York Times. This is the one that's getting on the front page of the New York Times: Psychotherapists are not practicing scientific methods and they won't. And again, there are two things wrong with that. One is that that is a sad shame if it's true, and second is that our definition of psychotherapy almost makes it impossible for psychotherapists to do otherwise.
HT: So in this particular paper, "Making Science Matter," you said something really salient. You said, "Despite all the evidence or lack of evidence that science matters so far, I still believe that scientific methods offer the best way of finding optimal and effective ways to intervene with behavioral health problems."
LB: That's right. That takes me back to my chemistry and physics. There are connections between things, and the best way to find them is to control variables and allow other variables to vary, and systematically evaluate the outcome.

Matching Therapists, Treatment and Patients

HT: What are the variables you think are important to study in a more broad kind of approach?
LB: There are so many of them. I think, increasingly, the evidence as I read it says
the maximal amount of change that we'll be able to account for is going to be embodied in the way therapist characteristics, treatment, and patient characteristics interact
the maximal amount of change that we'll be able to account for is going to be embodied in the way therapist characteristics, treatment, and patient characteristics interact--algorithms, essentially, that bring those three things together. Those will be the strongest contributors. It will not be therapy procedures, it will not be patient diagnosis, it will not be these other isolated variables. It will be the interaction among them.

And so I am very tied to looking at ways to match patients to therapists and match patients to treatment. And those are two different things, but they have to be incorporated within the same research model. There are certain things we find very difficult to randomly assign. The gender of the therapist, you know, that's difficult. We can assign male and female therapists, but we can't assign to a therapist a different gender and separate out of that connection what the therapist is from the gender the therapist assigns. So we've got to find more flexible research models that don't throw away the randomized clinical trial but add to it more correlational kinds of variables to put into that mix and evaluate the outcomes. And that, I think, is where science needs to go to become really relevant.
HT: I've taken your course twice, and in the class we read your book Systematic Treatment Selection4. And that model is what you're talking about: to try to capture the patient's characteristics, the therapist's characteristics, and to match them, and also looking at what kind of treatment approach will work best for a certain patient depending on the stage of their condition. Can you tell more about therapist and patient matching? What do you match them on?
LB: Well, again, the potential is limitless. But what we look at are four basic kinds of variables. And sometimes it's difficult to assign the ownership of those. Are they characteristics of the patient, the therapist, or the treatment? They should call it intervention, not treatment, because it describes what the therapist does, and we can only roughly categorize those into groups. Of the variables that we look at, the first one is really the impairment level of the patient. Now, the impairment level of the patient isn't just something owned by the patient. It's also owned by the context in which they live, the social environment, the culture, the value system that exists in that culture to define what is adaptable and not adaptable. So we can't just study functional impairment disembodied from the culture in which it lives.
HT: So it's really beyond the DSM-IV.
LB: Oh, way beyond the DSM-IV. But we can take functional impairment and say, once you have defined it within a cultural context, then there are a couple of things we can clearly say we know about that; one of them is that the more impaired the person is, the more treatment they require, the more varied kind of treatment they need to get, and the more it needs to extend into the environment in which they live. There's some real implications with this. This means family treatments need to be involved based on the impairment level. That means groups--social groups, not just therapy groups but social groups--need to be involved, and that the intervention needs to be more life consuming the more impaired the person is. But you need to start with how you define the impairment in the culture in which it's done.
HT: By life consuming, you mean more sessions, longer sessions?
LB: More sessions, longer sessions, and sessions out there, not in the office.
We need to help take the person out into the world in which they live, and therapists are still reluctant to do that.
We need to help take the person out into the world in which they live, and therapists are still reluctant to do that. The second variable we look at is the patient's coping style, but that too is a culturally defined variable. It reflects what works within the culture that one lives. It's clear to us now that at least people in many Asian cultures, certainly Japan and probably China, tend to cope with things in a much more internalized and self-reflective fashion. And the concept of collectivism becomes very important in the whole concept of coping. So we need to understand coping within the context of the culture it occurs in.

But within that there is variability, and it varies along this dimension of how one copes, how one deals with the self versus others, how one accommodates to others versus defends against others. Once we know that, then it can tell us a little bit about how we need to intervene, what kind of focus we need to take. And again, the effect sizes of this cut across cultures pretty well right now. Compare the effect size of cognitive therapy to interpersonal therapy: the mean effect size is zero. But if you can compare what we call a good match between the focus and the coping style of the patient, and a poor match between the focus and the coping style of the patient, we get effect sizes on average of 0.6 to 0.7. That's good--those are high effect sizes. That means that we're having a much more significant effect upon that patient by taking into account coping style than we are by identifying their diagnosis.

Then we take the next variable, which is a patient's resistance. And this is where we get some real problems. We've always thought that if a therapist can identify and deal with how the patient wards off efforts to persuade them or change them, then the therapist can adapt to that. And we find, in fact, that this only works in some contexts. For example, we just did an analysis of the effect size related to coping style and directiveness of the therapist. We've always thought that if the patient was very resistant, then if the therapist was less directive and confrontive they would be able to persuade them. But that seems like it may only work in North America. And it may only work with relatively serious problems. People with less serious problems and people that are outside of the North American value system may not always relate to that. In fact, very resistant patients in some cultures may respond well to a very directive, authoritative therapist. We don't know yet. And we don't know whether the therapist is able to change their level of directiveness. We don't know if it's a characteristic of the therapist or a characteristic of the therapy, or if you can even make those distinctions.
HT: Yes, I can see that--even with different therapists the resistance level would be different.
LB: Then the final thing we look at is the distress level. This is an aspect of patient adjustment, obviously. It becomes a problem of separating that concept from functional impairment, because your distress level changes functional impairment. People can't function well if they're highly distressed. On the other hand, they don't get motivated very well if they don't have some distress. So the real clinical struggle is to find that window in which they are motivated for change, because they are uncomfortable and they want to become comfortable. They're motivated for change but they're still functional.
HT: Distressed but not overwhelmed.
LB: And then if you're successful in therapy and help them lower their distress, what does that do? Does it take away their motivation to continue to work? There are some interesting answers with this that we don't know, but what we do know is that motivation, as embodied in concepts of arousal, are important in trying to facilitate and negotiate this road of psychotherapy. There is something here about the management of patient emotions. Helping them manage their emotions so they stay within a window, an optimal range that is very important. And many therapies talk about that, but it's real hard to define what the window is.

Lessons from Horse Training

HT: At the VA (Veterans Administration) we often say it's not only the distress but also the functional impairment that will bring the veterans in. So they will avoid seeking service until their relationship doesn't work.
LB: Things crumble.
HT: Yeah. They lost their job. And of course they're subjectively distressed, but they avoid that due to different reasons. But it's not until they're really impaired in their social or interpersonal occupational functions that they come in.
LB: Some people have a lot of tolerance for distress, and other people have very little tolerance for it. The levels of impairment and disruption in their lives become an additional factor in helping them. In fact, there's a principle in horse training that has been articulated by several different people in what's called the natural horsemanship movement. It says: Distress motivates, release teaches. But to take that analogy further--and I do find the analogy an interesting one--I got back into working with horses when I moved to California in about 1990. For the twenty years prior to that, I'd been flying airplanes and interested and enjoying airplanes, and then it just got too expensive to do, so I thought I'd get back into a cheaper kind of thing.
HT: And you didn't find a good analogy.
LB: I didn't find a good analogy in flying airplanes. It's very interesting because I used the airplane functionally. I used it to go from Point A to Point B, and it was fun to do. I traveled all over Texas trying to recruit students to our graduate programs and talking to them about psychotherapy and so forth. But the plane was a way to get there and have fun while I was doing it.

When I got back into horses I discovered that there are so many parallels with psychotherapy. And it has changed so much--it gave me some hope for the field. When I was a kid doing horses, we broke them. We really tried to bend their wills, and we forced them into positions. It took a long time, and it was hard to do, and they were always resistant. As I got back into it, I discovered a whole new movement had occurred, in which what was important in horse training was the relationship you had with the horse, not the technology you used to make the horse do something.
When I got back into horses I discovered that there are so many parallels with psychotherapy. And it has changed so much--it gave me some hope for the field. When I was a kid doing horses, we broke them. We really tried to bend their wills, and we forced them into positions. It took a long time, and it was hard to do, and they were always resistant. As I got back into it, I discovered a whole new movement had occurred, in which what was important in horse training was the relationship you had with the horse, not the technology you used to make the horse do something. So it was the development of a relationship that became important and that gave you the avenues to do all kinds of other things. And I saw people doing some marvelous things with horses that I'd never thought we could do when I was 15 years old and trying to do these things. And I started to apply some of that to psychotherapy.
HT: Like what?
LB: Like this concept of managing their arousal level. For horses, that becomes a central component of any training experience--to be able to raise it up and be able to release it, to stop it. With horses that's relatively easy to do once you get the concept and the additional one that says, well, if it doesn't work in big steps, take small steps. If we could apply just those two concepts to psychotherapy, I think we'd have greater levels of effectiveness than we do now. But we don't; we couch them in all kinds of other things, and the human condition makes it harder to observe when a person is optimally aroused, and it also makes it more difficult for a therapist to relieve that arousal, because they're responding to so many things out there.

I began to note that in a small, enclosed area anybody can train a horse to come to you when you ask it to. All you have to do is control those two basic principles. You control their arousal and you break it down into small steps. I could teach anybody to do that. But then when I said, "Okay, generalize that principle, take it out of that small, enclosed area, and teach a horse to do the same thing out there in a hundred acres," some people could analyze it and decide how to do it, but most people could not. I began to observe how psychotherapists learn to do something. To most psychotherapists, they see it as a technique, but to some psychotherapists, they see it as a principle. And that means that they can change it and still be true to the principle and apply it in a new situation to a new patient in a new environment. The difference between a technician and a therapist, an artist, is not that they don't follow the same principles. It's that they are able to translate them into new settings, new environments, and new ways of operating. And that's where the real art and science of psychotherapy come together: to identify what the scientific principles are, and then learn to use them creatively in new environments with new people under new circumstances. It's happened in horse training.
HT: But the challenge is how to apply these principles to human behavior.
LB: If it can happen in horse training, it may be able to happen in psychotherapy. We've got bright people working in psychotherapy. Can't they just move beyond that narrow view to be able to see the creative way of applying scientific principles?

Therapy Research Across Cultures

HT: So we've come back to evidence and science. And I know you've been working in Argentina, Japan, China. Any findings from the STS (Systematic Treatment Selection) approach? Any preliminary data that shows that it's a better alternative to the traditional "gold standard" of manualized treatment? What does the data say so far?
LB: The data is pretty clear, so far, that we can do a better job of predicting outcome and even controlling outcome by controlling things that include the context and the environment. I point to the coping style focus of therapy, for example. This seems to be a construct that does nicely moving across cultures. We don't know about all cultures, but many--we've tried in Northern Europe, we've tried in North and South America, we're beginning to try it in Asian countries. It's a general principle that cuts across culture, that
if you can identify variation in the coping style and then begin to fit the focus of therapy as either insight-focused or symptom-focused based upon that coping style, then we can facilitate change.
if you can identify variation in the coping style and then begin to fit the focus of therapy as either insight-focused or symptom-focused based upon that coping style, then we can facilitate change. Therapists seem to be able to change what they do, at least a little bit, to become more insight-focused or more symptom-focused. It is not a characteristic that's so closely bound to the therapist that they can't alter it.

The relationship between resistance and directiveness with therapy, that seems to be more difficult to generalize. That seems to be a characteristic that's very tied to the therapist--can they be both directive and non-directive? No. It's hard for them to do. The way that people resist and the way they respond to directiveness also varies across cultures.
HT: So you're identifying that some principles are universal but some are more culturally bound.
LB: That's the important aspect of all of this: being able to define what is generalizable from one place to another, and what is not. And what makes it generalizable and what inhibits it from being generalizable. People talk to some degree about this model of mine, this STS model, as being a common factors model, because it looks at the same variables across all of treatment. But it doesn't apply them the same. It asks specifically for variation in what one does as a function of the patient characteristic. It's not common across and it doesn't fit all therapeutic models, it doesn't fit all cultures. But we don't know all of the limits yet, so that's really where we're going.
HT: One thing that occurred to me is I've heard over the years that therapy is about what, when, who. But what you're talking about is the how. You're not talking about therapy itself, but rather what you're using with whom and when to use it. STS sounds to me like you're figuring out how to take all these factors into consideration.
LB: Yeah, that's what we're trying to do. We're really still addressing Donald Kiesler's concern of 1967, that there is still the myth of homogeneity of therapists and patients and so forth. And a real central question that Kiesler raised at that point was what treatment works with what patient under what conditions by whom. And we're still trying to do that. What psychotherapy as a field has done is move away from everything but the what. We want to incorporate the what, but we want to keep the who there, and for whom, by whom, under what conditions.
HT: That's amazing.
LB: It will be amazing if it works. Well, it does work. It will be amazing if it catches on. People, psychotherapists in particular, continue to look for something more simplistic than that.
HT: I'm thinking about China, where we have a limited number of therapists. It's really hard to do this matching, because many of them were trained in one approach, for example, a more dynamic approach, and they use this approach with everybody. And some of them were trained in CBT and they do CBT with everybody. And I think in the beginning of this kind of developing stage, it's almost inevitable.
LB: Yes, but the nice thing about the STS model that defines all of these principles is that you don't have to use all of them at once. If I could just give you one principle that could make a significant impact on your treatment that you could follow, for example, the fit of the impairment level of the patient to the intensity of treatment. The more impaired they are, the more they need a wide variety of different treatments, the more they need treatments that involve other people, the more they need treatments that involve the society out there. If I could just give you that principle, you could do substantial things to your effectiveness rates.

The other principle I could give you has to do with the coping style of the patient and the focus of treatment. If you could just change that--and you could do it within any model. I mean, Freud talked about symptom-focused kinds of interventions versus more insight-oriented interventions. The range of what the therapist does within a particular model is not as great as what they might do if they had a wider range of therapeutic models at their disposal. But they have some variability, and thus they have some choices, and could improve their effectiveness if they were just to apply one or two principles. I have no hope that people will apply more than five, because I don't think people can keep more than five in their head at once. The best thing we know, the closest thing to truth we have out of this whole field, is that they could make a very substantial difference in how effective they were in working with a wide range of the people by just taking one or two of the principles. You don't have to take the whole thing.
HT: But from an STS approach, the therapist needs to have expertise in more than one approach, right?
LB: Well, to be optimal, it would be nice. But it's not more than one approach. They have to have a toolbox that's filled with more things than screwdrivers. If you're going to do a job, you need to have a toolbox that's full of tools. So you don't just have reflection. You don't just have interpretation. Or you don't just have behavior reinforcement or contracting. You try to have a toolbox full of many of those things. And ideally you need to have a toolbox that's filled with individual interventions plus group and multi-person interventions. You need to have a toolbox that has in it both tools to increase distress and lower distress, that both focuses upon indirect change through insight versus direct change through behavioral reinforcement, and that gives you variation in being reflective versus being directive. If you have a toolbox that has some of those tools, you don't need the whole model. You don't need to buy psychoanalysis and have the whole training in psychoanalysis to do an interpretation. You have some tools to do it, and then what STS tells you is when you might optimally use each of those tools.
Don't use a hammer for every job you have. I mean, around the ranch I like to say, I can fix anything with a hammer. But you know, it's really not true.
Don't use a hammer for every job you have. I mean, around the ranch I like to say, I can fix anything with a hammer. But you know, it's really not true.

The Future of Psychotherapy

HT: So if I may, I have two more questions. One is more practical, and one is more broad and general. Let's go with the more practical one. If you're speaking to a group of entry-level therapists who are just starting their career in this business, what would you say to them about what they can do to be more effective therapists?
LB: The central theme: first is relationship. That's what I would tell the horse trainer, and that's what I would tell the psychotherapist. If I have one thing to tell them: learn to listen. And you'd be surprised at how difficult this is. But it's the one thing that they need to start with, the ability to sit and listen to another person without an agenda, without inserting some salesmanship, trying to sell a point or a point of view or a perspective. Don't sell a perspective. First, learn to listen. Now, for more advanced ones, then they can learn one principle at a time. The next principle I would say...
HT: How many do we have? How many principles do we have?
LB: We can have a hundred principles.
HT: Eighteen?
LB: Well, we've got 18 in STS, but we know there are more principles than that. But the ones that are going to have the most powerful impact are the principles having to do with the quality of the relationship, because most of the patients that you see will benefit just from that. They don't need anything else. So learn to listen. If you just learn to listen--I'm talking to you as everyone. You're a collectivist, right?
HT: I'm integrative.
LB: Integrative. All right. This perspective, if people could just learn to listen and to do it without inserting. It's called motivational interviewing, it's called client-centered therapy, it's called humanistic therapy. If you could learn that concept of listening, most people that you see would benefit from it without adding anything else.

And then if you were to add the principle of intensifying therapy with the level of impairment that a person has. Just those two concepts. If I could get that across to new therapists out there, they would make a huge difference. But they don't believe me. They say, "research be damned." They don't believe me.
HT: How many years did it take you to come up with these ideas?
LB: What am I? I'm almost 69.
HT: It's 50 years of wisdom.
LB: At least.
HT: At least. No, every year counts--69 years. Okay, one last question--it's kind of a broad one. What do you think of the future of psychotherapy, or the best possible approach to psychotherapy?
LB: Well, those are two different questions. My greatest fear is that psychotherapy will continue to persist in this fragmented way, and that we will see an increasing schism between the science of psychotherapy and its practice. And people will continue, as practitioners, to try to sell a point of view that is needed and will be valued, but which society will not ultimately support because society has a price tag attached to everything. And what the price tag is going to say is that you have to be able to prove what you do, and you have to be able to replicate it. That means we're going to have to move increasingly towards a broad view of science. Though I don't know, frankly. Back in 1970, George Albee, then president of APA, was asked to write an article on the future of psychotherapy. And I believe completely what he wrote, which was four blank pages. It has yet to be written.

I believe there will always be a place for people who can listen and who can provide, through whatever means they can, the experience of help to other people. There will always be a place for that. I don't think that we will continue to support it through health care indefinitely, because we will have to accept the fact that it is not health care--it is life care. Society is forcing us into that in part by credentialing all these other quasi-therapists--you know, life coaches, etc.--that have taken away the things that we used to call psychotherapy, and now they use them under a different label. And it tells us something: that our view has been too narrow. Within the narrow view that we use--psychotherapy to treat psychopathology--we're going to have all kinds of medical, biological, chemical treatments to do away with symptoms. What we won't be able to do is change a lot, through this chemical interjection, some of the basic angst that people experience in not being connected to other people, not being heard, not feeling relevant. Having another person, someone who is be trained to do something that is helpful and optimal, who will listen and care for them, is going to continue to be very important.
HT: Thank you so much, Larry. Thank you for your time and wisdom.
LB: Well, I don't know how wise it is, but you got it.
HT: Thank you.

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CE Test
Larry Beutler

Dr. Larry Beutler received his PhD from the University of Nebraska and subsequently served on the faculties of Duke University Medical Center, Stephen F. Austin State University, Baylor College of Medicine, the University of Arizona Health Sciences Center, and the University of California at Santa Barbara.

He is currently a Distinguished Professor of Psychology and Director of Education and Training for the National Center on the Psychology of Terrorism, a joint program of PAU, Stanford University, and the Naval Post-Graduate School. He is a diplomate of the American Board of Professional Psychology (ABPP), a fellow of both APA and APS, a Past President of Division 29 (Psychotherapy) of APA, current President of Division 12 (Clinical) of APA, and a two term Past President (international) of the Society for Psychotherapy Research (SPR).

Among his citations and achievements, he is a recipient of the Distinguished Career award from SPR, the Gold Medal Award from the American Psychological Foundation, and a Presidential citation for achievement from the APA. He has published over 350 scholarly articles and chapters and is the author or co-author of 20 books on psychotherapy, assessment, and psychopathology.

Hui Qi Tong Hui Qi Tong, MD, PhD is a graduate from Shanghai Medical College, Fudan University and a psychiatrist by training before she came to the United States in 1995. She was a research fellow at the Genetics Division, Children's Hospital Boston, Harvard Medical School, Clinical Research Associate in the Psychiatry department, Tufts University, School of Medicine and a research collaborator and content expert at the Older Adult and Family Center at Stanford University, Department of Psychiatry and Behavioral Sciences. Hui Qi graduated from Palo Alto University (formerly Pacific Graduate School of Psychology) with a PhD in Clinic Psychology in 2008. Currently, she is a staff psycholoigist with the Women's Clinic and PTSD Research Program at San Francisco VA Medical Center and program coordinator for UCSF Global Health Sciences/ Global Mental Health Program. Her main clinical and research interests are in trauma, women's mental health, suicidal behavior, attachment and psychopathology, cultural adaptation of psychotherapy and the integration of Eastern and Western approaches in psychotherapy and related topics. She has co-authored or co-edited about 30 papers and chapters and translated one psychotherapy book into Mandarin, Every Day Gets a Little Closer: A Twice-Told Therapy: by Irvin D. Yalom and Ginny Elkin. Currently, she is translating Sophie Freud's: Living in the Shadow of the Freud's Family.

Hui Qi is also the founding president of American-Chinese Academy for Psychotherapy (A-CAP), a non-for-profit organization established in the Silicon Valley with the mission of addressing mental-illness-related stigma and discrimination and promoting mental health among the Chinese communities both in USA and in China and promoting evidence-based psychotherapy in China through teaching and training (website under construction). Contact Hui Qi Tong.

CE credits: 2

Learning Objectives:

  • Describe Beutler's approach to blending research and clinical practice
  • Discuss Beutler's ideas about training new psychotherapists
  • Explain Systematic Treatment Selection's relation to therapeutic effectiveness

Articles are not approved by Association of Social Work Boards (ASWB) for CE. See complete list of CE approvals here