What should be different as we train the next generation of therapists? Which, if any, ideas in the field do we need to retire as we move forward? Competent trainers will eventually ask themselves these questions. And here, Stefan Hofmann—whose widely disseminated research on CBT and contributions to the DSM have shaped the way many of us practice—offers some surprising answers.
Good therapists, even those with drastically different approaches, have a similar convergence of skills, or core competencies. They know how to talk to people. They know how to see the world from their clients’ viewpoints. They know how to solve problems. They know how to be empathic and feel the struggle, and then find ways of moving beyond it to get clients out of stuck points by, for example, changing maladaptive habits or thinking patterns. It’s not a very large list of things to be good at really, and thankfully, our training programs are moving toward identifying these to our students.
Simultaneously, we need to step away from tribal fights in psychotherapy. Rather than thinking in terms of what training each of us has, let’s embrace a move toward a more liberal philosophy about the best tools we can use for our clients and how to combine them in the best possible way for a given person. It’s analogous to going to a doctor for heart problems. That doctor hasn’t chosen from different schools or philosophies of how to treat heart problems. Good doctors know what to do with the tools at their disposal to treat the specific client.
Don’t Be a Cult Member
I’m a CBT practitioner and researcher, and I think that as practitioners incorporate emotion-regulation strategies, a consideration of cultural issues, and a focus on attachment issues and trauma that are not within the core CBT approach, there comes a time when it doesn’t make sense to even use the term cognitive behavioral therapy. And that’s okay, because it isn’t helpful to the science or to clients to identify yourself with a given orientation anyway.
You might get a kick out of using your favorite philosophy to think things through, but it’s not you or your philosophy that should determine how best to implement therapy strategies. Which strategy fits a given client is the critical piece of being a good clinician. And that’s what we need to train for.
“Therapists are extremely powerful people, and we’re at a point with what we know that we don’t need to wait for any new techniques to arise. Let’s be energized by that in our work and in our trainings.”
You could be an insight-oriented therapist who’s treating a person with worry or a phobia, but you’d still want to use exposure strategy for the phobia, because we know that works. It’s not all they need—you might also consider whatever trauma history and attachment styles might be relevant—but you’ve got to use it to practice your profession well.
Banish the Latent Disease Model
We need to step away from the simplistic latent-disease model that people have been adopting. It’s not only the DSM that’s to blame for this, but also biologically oriented psychiatrists who’ve tied human functioning to neurotransmitters or circuitries, as well as psychodynamic practitioners who’ve suggested that there’s latent disease behind surface problems. All of that may or may not be correct, but none of it is relevant to optimally treating a client. You need to understand people’s problems as they themselves present them, and how these problems are linked and maintained.
It may be too much to ask any therapist to understand a client’s complete network of problems, but we can at least broaden our own lenses so we’re not just focusing on small aspects of problems that seem to only align with our personal or theoretical orientations. To capture that complexity, we’d want to look at cognition, behavior, self-related processes, and attachment styles, along with emotion regulation, motivation, and relevant sociocultural issues. For training, the core competency is a list of a dozen or so things that you need to know as a therapist, and every clinician can be trained in them.
Question Protocols for Syndromes
It’s nonsensical to have trainees go through different theoretical orientations and contrast them, or read thousands of different protocol-for-syndromes books. I’m afraid that this protocol-for-syndromes game started with CBT showing good alternatives to pharmaceutical therapy through randomized controlled trials. I’ve been developing these treatment protocols and involved in creating the DSM for a big portion of my life—and yes, we’ve been able to relieve suffering in many people, but many others still remain highly symptomatic. Clients are much more than the sum of their symptoms, and treatment should focus on much more than just symptom reduction.
Most importantly, being consumed with studying one variable at a time, as if that’s what’s between treatment and outcome, hasn’t advanced the field much. Honestly, who really thinks that therapy is a result of changing one single variable? It’s ridiculous. Instead, we should see the individual client as a complex network and therapy as a process to change a maladaptive network to an adaptive one through core therapeutic strategies that target specific processes.
What we need to focus on is evidence-based processes and understand what’s actually happening in therapy. What changes client self-perception, and emotional regulation, and behavioral-motivational tendencies, and value-based issues? Once we know, we can target that through a number of different strategies. Rejiggering the field to produce therapists who focus in this way is complicated, but we have the tools available to make it happen if we work together.
A Stifling DSM
The DSM hasn’t helped us in this pursuit. If anything, it’s stifled research, and there’s no indication that it will change. The most common DSM diagnosis given by clinicians in practice is “diagnosis not otherwise specified.” And there are no real, prototypical patients for these different disorders. People are too different from one another. It doesn’t make sense to group them together by surface problems.
The way we’ve been trying to simplify the entirety of psychopathology has been incorrect. We need to go back to understanding how problems are connected and then reconfigure how we work. Someone might come to your office saying they don’t sleep well at night and they’re having problems paying attention for long periods of time. There’s an obvious connection there. It’s certainly possible that depression is causing their attention problems, but it’s also possible that the sleep disturbance is to blame.
You can test it. You can encourage the client to see if the sleep they get the night before has an effect on their attention the next day. If it does, you then work on the sleep problems. Yes, it’s a simplistic idea, but you don’t have to assume that depression is causing both things. It may be, but it’s not necessary to work from that assumption to adequately treat the person.
Let’s remember that all of us commonly experience maladaptation because our context is always shifting and requiring us to change. That’s the broad framework evolutionary science gives us—broad enough for any orientation to accommodate.
Getting to the Core
I think the development of different therapies for some 40 or 50 years has been driven by a very simplistic idea of the DSM. We started out as universalists, all of us. Freud didn’t develop psychoanalysis for borderline personality disorder: he developed psychoanalysis. [Aaron] Tim Beck didn’t develop cognitive therapy for panic disorder: he eventually wrote books on that, but he developed cognitive therapy, period. The syndrome game has moved us in an odd direction.
It’s unfortunate because we became technicians in particular areas, and that’s not who we are or who we should be, and it’s not how we best serve our clients. We have to step away from a nomothetic latent-disease model and instead go back to our idiographic roots of functional analysis in a humanistic context if we really care about the human beings in front of us.
A few years ago, the Association for Behavioral and Cognitive Therapies convened an inter-organizational task force to come up with core competencies every graduate training program should deliver, regardless of orientation. This list included how to implement exposure, cognitive reappraisal, relaxation strategies, problem-solving strategies, motivational interviewing, and good interpersonal relationship skills. I’d feel good about sending a relative to a therapist that knows how to do these things.
When I taught at Boston University, I designed a class around these issues, and it was easy to do. These competencies—and our intrapsychic and interpersonal processes, including those within the family and culture—should become clear parts of the doctoral and masters curricula.
I think the important thing is to not be alienated by what I’m saying. Therapists are extremely powerful people, and we’re at a point with what we know that we don’t need to wait for any new techniques to arise. Let’s be energized by that in our work and in our trainings.
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