Twenty five years ago, in 1982, the first issue of the Psychotherapy Networker was published. That same year, American Psychologist surveyed 800 members of the American Psychological Association to learn which theoretical clinical orientations they followed and which psychotherapists they believed to be the most influential in the field.
On the 25th anniversary of this magazine, it seemed appropriate to revisit these questions, take stock of our profession, and get a sense of how therapy has developed and changed over
the years. So, we partnered with Dr. Joan Cook at Columbia University and her research project funded by the National Institute of Mental Health to find out ourselves, posing the question, “Over the last 25 years, which figures have most influenced your practice?” Respondents could list up to 10 different sources of influence if they wished. We also asked recipients for information about their own approach to treatment—what model or combination of models they used. We received 2,598 responses—a far larger number than the 422 returns in the 1982 survey.
Perhaps the most surprising single finding was that in both the 1982 and the 2006 survey the single most influential psychotherapist—by a landslide—was Carl Rogers. In other words, the therapist who became famous for his leisurely, nondirective, open-ended, soft-focus form of therapy 50 years ago remains a major role model today, even with the explosion of brief, “evidence-based” clinical models, a psychopharmacological revolution that often makes medications the intervention du jour, and a radically altered system of insurance reimbursement that simply won’t pay for the kind of therapy Rogers did. He and the remaining figures voted by the survey respondents to be among the top 10 most influential therapists of the last quarter-century are recognized in the pages that follow.
Who are the people responding to the survey? They are most likely female (75.9 percent of respondents), white (90.5 percent), middle-aged (the mean age was 50.79 years), and either social workers (34.7 percent), professional counselors (21.1 percent), or psychologists (16.6 percent). A few called themselves drug/alcohol counselors (1.3 percent) or “other,” including clergy member, school counselor, and “psychotherapists” not further defined (8.2 percent). A vanishingly small sprinkling of professional groupings make up the remaining 2+ percent.
The majority of survey participants graduated between 1990 and 2006, though a significant number received their most advanced degrees between 1970 and 1989. A surprisingly large percentage—41.4 percent—are relative novices, having practiced for from 0 to 10 years (suggesting, given their mean age, that, for many, therapy is a second career, or else that the kids have at last moved out). A little more than 30 percent have practiced between 11 and 20 years, 21.2 percent between 31 and 40 years, and the rest (8.3 percent) are real old-timers, having been therapists for between 40 and 54 years.
How do our clinicians identify themselves? What kind of therapy do they actually practice? As with the therapists who influenced them, respondents could mention a range of different orientations that comprised their approach. Perhaps the most important finding is how eclectic most therapists are. Of 2,281 completed and valid surveys (not all of the 2,598 responses contained enough information to determine clinical approach), only about 95 respondents (4.2 percent) were purists of one sort or another, meaning that they described themselves as using one model virtually exclusively. The rest—95.8 percent—admitted to combining a variety of approaches.
Even though Rogers was named the most influential therapist, the most popular therapeutic approach—what most people in our survey really do at least part of the time in their practice—is cognitive-behavioral therapy (CBT). Of the 2,281 fully completed responses, CBT is used (mostly in combination with other methods) by 68.7 percent, or 1,566 people. Only 31 percent of the respondents own up to using a “Rogerian/client-centered/humanistic” approach at all, even in part, and only one lonely soul admitted to being exclusively Rogerian. Oddly enough, just about the same percentage as those who use Rogerian methods don’t use CBT at all. Are these CBT refuseniks and the Rogerian holdouts the same people? How do they get paid?
The second most used model, after CBT, is marital and family systems (1,135 respondents and 49.8 percent), but half say they don’t use MFT at all, and only .4 percent (about 9 people) identify themselves exclusively as MFT therapists. And yet, three of the most influential therapists named this time are Salvador Minuchin, Virginia Satir, and Murray Bowen—so why aren’t there more MFT practitioners? Looking back, in 1982, when the family therapy movement could still claim some revolutionary fervor, the only actual family therapist listed in the top 10 most influential psychotherapists was Jay Haley (who was number 8). And only 2.6 percent of the respondents to that survey (11 individuals—admittedly from a small pool) said family therapy was their orientation. It seems likely then that while the family therapy revolution is now over—at least in all its doctrinal purity—the revolutionaries actually won, in that systems thinking has been incorporated by a broad swath of therapists all across the clinical spectrum.
Third in line of favored orientations is something respondents call “mindfulness” therapy—945 therapists, or 41.4 percent use it. Psychodynamic/ psychoanalytic makes up the fourth most popular category, with 808 adherents or 35.4 percent. Only .5 percent—about 11 respondents—consider themselves exclusively psychodynamic. The contrast with 1982 is striking, when 45 of 415 respondents reporting their theoretical orientation claimed to be “psychoanalytic”(almost 11 percent).
It isn’t surprising that the 10 most influential therapists in our survey are all in their own way originals, each with a unique and compelling vision. Just as important as their ideas, however, is their outsized endowment of pure, big-P Presence. Though they may be first-rate researchers, original theorists, prodigious writers, charismatic teachers, and extraordinary clinicians, what sets them apart and makes people remember them is that they have the bone-deep conviction, unstoppable energy, and inspirational force of born proselytizers.
As a measure of how powerful these individual voices are, it’s difficult to read, hear, or see them without becoming completely convinced that each one in turn has the answer not only to every human dilemma, but to your own specific human dilemma. Whether it’s the limitless compassion of Carl Rogers, the razor-sharp analysis of Murray Bowen, the hypnotic persona of Milton Erickson, the shimmering vitality of Virginia Satir, the comical genius of Albert Ellis, the tragic imagination of Irvin Yalom—they all seem to embody within their very cell structure a wisdom that, at least in their direct presence, leaves no room for doubt. Of course, you find yourself thinking over and over, this person is absolutely right!
That you say that anew with each person, although the particular vision of each is so different from that of all the others, could suggest that the whole field of psychotherapy is nothing but a potpourri of personal opinions pushed by outsized egos. But in fact, the individual variation and brilliance of each distinct voice simply enhances the reputation of a profession that may actually come close to encompassing the vast and complex reality of human psychology itself.
1. Carl Rogers
Virtually all therapists today are “Rogerian” in style, no matter what their clinical or theoretical orientation, or what they think of Carl Rogers. Does any clinician not subscribe, at least in part, to the holy trinity of Rogers’s psychotherapeutic method: “unconditional positive regard” or full acceptance of clients as they are; complete empathic understanding of clients, clearly communicated to them; and “congruence,” or being authentic, genuine, and transparently “real” with clients? What therapist, no matter how hard-nosed, directive, and manual-bound, doesn’t program at least a little “reflective listening” into his or her work from time to time?
Not that any of these ideas were, strictly speaking, invented by Rogers—no psychotherapy is really thinkable without them. Still, Rogers was probably the first to put them all together in one comprehensive package, which during the ’50s, ’60s, and ’70s became an almost universal therapeutic credo, even a brand identity that determines to this day what most people—lay people at any rate—think of when they imagine what a therapist is or does. Carl Rogers, you could say, was a kind of Mr. Rogers for grown-ups.
In fact, Rogers could fairly claim to be the most American therapist. A small-d democrat down to his toes, he popularized the word client (which has since become almost ubiquitous in the field), suggesting an independent, self-directed customer seeking a perfectly ordinary service in the public marketplace, rather than a sick, helpless patient, the lowest rung of the medical hierarchy. He democratized psychotherapy itself, and did his best to deflate the delusions of grandeur held by some of its more august practitioners by purposely blurring the distinction between psychotherapist (usually applied only to psychiatrists and psychoanalysts) and counselor, a basket term enclosing just about anybody who gave people helpful advice—social worker, clergyperson, schoolworker, teacher, nurse, lay facilitator of self-help groups, even a good friend.
Rogers rejected the determinism of both Freudian psychoanalysis and Skinnerian behaviorism. In his view, Freud’s disenchanted take on human nature was “Calvinistic” in its emphasis on the “the evilness of the natural man,” and he compared Skinner’s behaviorist utopian fantasy, Walden II, to George Orwells’s 1984, a dystopian allegory based on Stalin’s totalitarian state. Rogers thought that the “self-actualized” or “fully functioning” person was by definition a subjectively free being. While not nearly as idealistic about human nature as his detractors insisted—he recognized our species’ capacity for cruelty, destruction, immaturity, antisocial behavior, and all-round nastiness—he believed deeply that all human beings trend in “basically a positive direction,” inherently “forward moving, constructive, realistic, trustworthy.”
Rogers also democratized the relationship between therapist-counselor and client. He believed that clients themselves—not their shrinks, however highly degreed—knew best what was hurting them and what needed fixing. Their own inner knowledge just had to be gently coaxed out, given an opportunity to emerge like a tender green shoot in the warmth of the spring sun. Clients didn’t need to have their words “interpreted” back to them. What they needed was the undemanding presence of a compassionate, deeply attuned listener, who didn’t diagnose them, explain their problems to them, ask many specific questions, lead them in particular directions, or tell them what they should do.
Rogers’s famous nondirective approach, based on “reflective listening,” has always been too easily corrupted by people who ran with the technique, but left behind the unique Rogers genius for hearing what clients couldn’t quite say. In the original, a friendly, receptive, interested, and unshockable therapist takes in and accepts whatever the client brings to the encounter and then reflects it back in a way that not only demonstrates understanding, but clarifies for the client the meaning and feeling of what the latter has just revealed. But it was a famously easy style to parody.
Rogers was often blamed for the worst excesses of the ’60s and ’70s counterculture. “As the founding father of humanistic psychology, the human potential movement, and the encounter group, Carl Rogers has a lot to answer for,” historian Christopher Lasch wrote darkly in a 1979 review of Howard Kirschenbaum’s biography, Being Carl Rogers. Lasch and other critics essentially accused Rogers of fomenting a runaway, nationwide cult of narcissism and irresponsible individualism, inventing and leading encounter groups that promoted sexual free-for-alls, undermining marriage and morality, and even causing nuns and priests—attending church-sponsored group sessions—to betray their vows (particularly celibacy) and flee the church in droves.
And yet, if history is any guide, Rogers’s continuing influence has more than defeated his critics. Over the last decade and a half, psychotherapy research has repeatedly demonstrated that the success of counseling and therapy depends less on any particular method than on the “common factors” shared by virtually all therapists—support, empathic understanding, positive regard, genuineness, and the ability to establish a strong emotional bond with clients. Furthermore, neuroscience research—for example, the recent discovery of mirror neurons in the premotor cortex that help explain how we “read” each others faces, gestures, and feelings—has substantially reinforced Rogers’s intuitive understanding of human connection. Increasingly, brain science has established that the sense of attuned connection that the therapist forges with a client works in therapy because we’re neurobiologically wired to respond positively to positive emotional signals from others. The responsive, attentive, caring, comprehending human presence is the most powerful force for emotional healing that exists or ever existed in the world. Every person who’s ever tried to help another suffering human being knows it.
Rogers knew it and tried to build a true science around it. Now, at last, science is finally catching up to Carl Rogers.
2. Aaron Beck
If all therapists today are at least a little bit Rogerian, it’s probably true that most of them are also a little bit Beckian. “Cognitive therapy” (as Beck called it originally), emerged quietly and unobtrusively on the scene in the 1960s, invented more or less simultaneously and independently by Aaron Beck and Albert Ellis. It’s now, 40 years on, the blockbuster success called cognitive-behavioral therapy (CBT).
The genius of Beck’s method was not only its brevity and effectiveness, but its easily replicable methodology, which lent itself readily to clinical trials. Beck not only developed a systematic model of brief therapy based on the notion that distorted thinking sustains depression and anxiety, but also perfected an empirically testable clinical technique, which he himself immediately began testing and fine-tuning. It’s hard to imagine that, whatever its intrinsic merits, CBT would have come as far as it has if not for Beck’s own indefatigable research and astonishing productivity—20-odd books and 514 academic journal articles and still counting (he’s written 474 papers since he was 50!).
The man behind what’s been called the “Beckian revolution” is today a mild, courteous, 85-year-old gent with snow-white hair and a signature red bow tie. In his youth, he wasn’t a firebrand bent on radically transforming the world of psychotherapy. He didn’t even want to be a psychiatrist. A Yale medical student with a scientific bent, he decided to specialize in neurology because he liked its “precision.” Obliged to take an unwanted rotation in psychiatry, he found himself swept up in the psychoanalytic enthusiasm taking hold in the school’s psychiatric division.
He decided to train as an analyst, which meant getting himself analyzed, an experience he found thrilling. “It seemed to reveal whole worlds about which I had no intimate knowledge,” he’s said. Now a true believer in Freud, his first research mission was to prove scientifically that Freud was right. So, during the late ’50s, with a National Institute of Mental Health grant under his belt, he set out to demonstrate empirically the correctness of psychoanalytic theories about depression.
One theory was that depression was actually unconscious hostility and aggression turned inward. To test this hypothesis, Beck examined his patients’ dream material—Freud’s royal road to the unconscious—which, according to the theory, should have been seething with repressed anger and destructive impulses. He found instead that depressed people’s dreams were filled with the same feelings of defeat and victimization that characterized their conscious waking life. For Beck, this was an early hint that deep psychological truth wasn’t always deeply buried. “What we see,” he says, “is what we have.”
Beck later got clues that the surface was itself very deep. In a famous Beckian set piece he’s described many times, he recalls an early patient he saw who described to him her adventurous sex life in lurid detail. After an hour of particularly action-packed disclosures, he asked her how she felt. “Very anxious,” she replied. When Beck probed further, she said that the reason she felt anxious was that she was afraid she was boring him! Surprised that after months of free association she’d never mentioned this, he asked her if she often thought she was boring. All the time, with everybody, him included, she replied.
It was a revelation—her anxiety and need to impress people may have had roots in early childhood, but it was clearly maintained by her constant belief that she bored people. Once Beck knew this, he could help her examine the evidence for her entrenched idea, and when it was found to be entirely lacking—all the evidence pointed in the opposite direction—she could begin to see that she was, in fact, quite an interesting person. It was, apparently, the key that cured her depression.
Beck began having his other depressed patients sit up and face him (rather than lie down on the couch), so he could see their expressions and body language, and asked them what they were thinking. All responded by saying things like, “I’m stupid,” or “I’m boring,” or “I’m a terrible failure.” The constant drip, drip, drip of these automatic thoughts poisoned their entire existence. Amazingly, however, as Beck recalled in an interview with Sidney Bloch in 2004 for the Australian and New Zealand Journal of Psychiatry, “when I focused on these negative thoughts, patients got better fairly soon, in 10 or 12 sessions.” From these almost incidental beginnings, a mighty empire grew.
Enthusiasts for CBT have often been subject to accusations that they do therapy by rote, and give short shrift to all the old virtues of therapy, like compassion, empathy, and the like. Not Beck, however. “Therapists who are good at the technical end of cognitive therapy fall flat on their faces when it comes to the more complex case,” he said in the same interview. “Empathy, sensitivity, considerateness—together with the ability to put them together with technical aspects—is the combination needed.” So, it appears, the father of cognitive therapy—the most “mental” of therapies—is another Rogerian!
3. Salvador Minuchin
Salvador Minuchin’s background is as unusual for a therapist as the family therapy methods he pioneered in the 1960s and 1970s. Born in 1921, he was a street-fighting Jewish kid in the anti-Semitic culture of Argentina. As a college student, he was jailed for three months for protesting the government of Juan Perón. He served as a doctor in the Israeli army during that country’s first wars. Later, studying psychoanalysis in New York City, he worked with black and Hispanic street toughs, whom he had the background to understand.
The traditional therapeutic techniques he’d been taught didn’t work with his young clientele. To reach these rebellious and unhappy youths, Minuchin hit upon the idea of treating them not individually, but with their entire families. He and his colleagues had no theories to draw upon in doing this—they observed and acted on their observations, experimenting audaciously. In Minuchin’s words, they “gradually articulated a correct method of working. We weren’t dealing with the way people think about relationships, but the relationships themselves.” Using this new approach, Minuchin and his colleagues changed the lives of youngsters who’d previously been considered clinically unreachable.
His vision was heroic. “We were trying to liberate people of low socioeconomic background. We believed in social revolution, which made it all very exciting,” he recalls. Recruited by the Philadelphia Child Guidance Center and working with people like Cloe Madanes and Jay Haley, he created the template for the emerging field of family therapy as set forth in his classic 1974 text, Families and Family Therapy.
Minuchin’s approach was linked inextricably with a unique personal style. Brusque but suave, somewhat rakish, with a trim moustache, dark-rimmed glasses, and a thick Spanish accent, he worked with families like a veteran theater director rescuing a troupe of amateur actors from their messy improv. The actors might be mystified by what he was doing and not necessarily happy with their parts, but they couldn’t resist his charismatic force.
Videotapes of his interactions capture his legendary therapeutic impact: Minuchin could size up a family in three minutes, then in rapid succession, he’d mock, reassure, flatter, charm, needle, encourage, congratulate, and confront them, ordering them around, joking with them, touching them, and herding them from chair to chair like a scrappy border collie. He’d throw them off-balance by looking bored and staring vacantly into space, smoking a cigarette, while they went on haltingly interacting, until suddenly he’d hammer a point home with high intensity, crowing in delight. Sounds like fun, doesn’t it?
To a field emerging from the stultifying methodology of psychoanalysis in the 1970s, with its snaillike pace and verbal meanderings, Minuchin was a revelation. Watching him in action was to see old psychoanalytic commandments smashed to smithereens—he swept away the dusty ethos of passive taciturnity, infinite discretion, and unassailable privacy, trampling underfoot the standard assumption that nobody can change anybody else, that psychological change must come from within. He poked, prodded, and jollied client families into changing right then and there, insisting that, in the words of his colleague Jorge Colapinto, “It’s through the power of human context—our relationships with each other—that we change.”
Another standard assumption he rode roughshod over was the idea that people’s feelings have to change before their behavior can change. Minuchin not only made people change, he seemed to do it regardless of what they were feeling, or whether they even knew what they were feeling. He acted on the premise that if you change the way people relate to each other, their feelings will change as well. This premise—that relationships change people—so commonplace now, so novel then, opened the door to an astonishing new view of personality itself. Says Braulio Montalvo, one of Minuchin’s earliest colleagues: “Personality has always been assumed to be something innate to a person, something solid and static, as if made of stone. But Sal could examine a family in a way that showed how malleable human personality was—that it shifts according to context.”
With typical verve, Minuchin described his approach in terms as far from dry theory as one can imagine:
“The idea was to help the dancers dance, and the therapist would be the one leading the do-si-do.”
It still sounds like fun.
Irvin Yalom is a consummate storyteller, whose stories are mainly about therapists, their patients, and the complex ritual called psychotherapy. He’s one of the field’s leading experts in group therapy—his magisterial work on the subject, The Theory and Practice of Group Psychotherapy, has gone through five editions and sold more than 700,000 copies since first published in 1970. He’s also the country’s best-known theorist and practitioner of existential psychotherapy. And yet it’s undoubtedly his works of fiction about psychotherapy that have made him famous, including the bestselling books Love’s Executioner, When Nietzsche Wept, and Momma and the Meaning of Life.
The son of poor Russian Jewish immigrants, he might have become a writer. But in the “ghetto mentality” of his youth, writing wasn’t an acceptable career choice for an upwardly mobile youth. Medical school, he remembers in an autobiographical note, “seemed closer to Tolstoy and Dostoevsky” than business.
A beginning psychiatric trainee, he was assigned as his first patient a lesbian, whom he was to see twice a week for 12 weeks. He knew nothing about psychiatry or therapy, and certainly nothing about lesbianism. “What could I possibly offer her?” he writes in the introduction to The Yalom Reader. “All I could do, I ultimately decided, was to allow her to be my guide and to explore her world as best I could. Her previous experience with men had been horrendous, and I was the first of my sex to listen, respectfully and attentively, to her. Her story touched me. I thought about her often between our meetings, and over the weeks we developed a tender, even loving, relationship.” The woman improved rapidly.
At the presentation of the case for his fellow students, psychiatric faculty, and various psychoanalytic bigwigs, he talked about the meetings with this patient and the loving feelings they’d developed. Normally on these occasions, the assembled experts harshly questioned the presenter. This time, however, nobody interrupted. Afterward Yalom was astonished to receive “lavish, even embarrassing, praise” from some, while others said his presentation “spoke for itself and nothing more needed to be said.”
This event was an epiphany. How had he evoked such an unexpected response from his audience? Not because of his psychiatric knowledge or clinical expertise, of which he had nil. “What I had done was something quite different” I had conveyed the essence of my patient and our relationship in the form of an interesting story.” Not only did the experience convey the power of narrative to bring “case histories” to vivid, blooming life, but it wakened in Yalom the realization that has been central to his approach ever since: patients can be fully known and understood only from their stories and from the relationship they form with a therapist.
Yalom’s work seems to argue that most psychodynamic therapies don’t go nearly deep enough. For him, the universality of death, the awareness that the grim reaper’s leering mug is always just around the next corner if not right in front of us, requires a certain humility in the therapist. “Everyone—and that includes therapists as well as patients—is destined to experience not only the exhilaration of life, but also its inevitable darkness.” Rather than maintaining the distinction between “us” (the healers) and “them” (the afflicted), he prefers to think of therapists and patients as “fellow travelers . . . all in this together, [with] no therapist and no person immune to the inherent tragedies of existence.”
What kind of therapy does an “existential therapist” do? For Yalom, the most important antidote to existential despair—the fear of meaninglessness in the face of certain death—is full-blooded human engagement and commitment, the lack of which probably brings most patients into therapy in the first place. In fact, engagement, he writes in the prologue to Love’s Executioner, “is where therapists must direct their efforts—not that engagement provides the rational answer to questions of meaning, but it makes these questions not matter.”
Yalom’s therapeutic credo might be summed up with his own simple directive to other therapists: “Let the patient matter to you.” He illustrates what he means by a counter example, the story of a well-known therapist with whom he studied as a young psychiatrist. The therapist, 70 years old and about ready to retire, was disbanding his own therapy group, which had been running for 10 years. Yalom sat in on the group’s final sessions as the group members reviewed the preceding decade, sizing up their individual accomplishments, marveling at how each one had grown and developed over the years. Everyone in the group had changed tremendously, they agreed, all except one person—the therapist. Afterward, talking to Yalom, the therapist said with great self-satisfaction, tapping the desk for emphasis, “That, my boy, is good technique.” Not to Yalom it wasn’t. “He had spent 10 years with these people without letting them influence or change him at all—he hadn’t let them matter to him. This was the saddest story about therapy I ever heard.”
It isn’t a story that will likely be told about Yalom. And perhaps this is why he matters to so many therapists and nontherapists who have read his books or heard him teach. “Nothing the therapist does,” Yalom has said or written various times, “takes precedence over building a trusting relationship with a patient.” It’s not hard to understand why so many people either want to be a therapist like Yalom or be his patient. If you can do both, so much the better for you.
The 1964 publication of Virginia Satir’s Conjoint Family Therapy presented her down-to-earth introduction to the art of this new therapeutic approach, confirming her reputation as a pioneer in the field. From the early ’60s—when her six-foot frame was augmented with three-inch heels and several inches of bouffant hair-do—the charismatic and controversial Satir loomed as a giant among therapists. Constantly on the road to the end of her life, she was a roving ambassador, even an evangelist, for a vision of family therapy as the means of healing a wounded world.
The hallmark of Satir’s work was her extraordinary sensitivity to the nonverbal aspects of communication—height differentials, distance, voice, tone, eye contact, posture, touch, and movement. Much of the magic of her therapeutic style was the ease with which she used these nonverbal dimensions. She believed that if she could help her clients see, hear, and feel more, their personal and interpersonal resources would lead them to their own solutions. Lori Gordon expressed what many observed: “No one could hold on to their own pathology around Virginia.”
It was always difficult for Satir to describe a family in abstract terms. Only when she was engaged with them fully with all her senses would she allow herself to think conclusively about the family system. And she always included herself in the description. So she might say, “I felt a warmth within that told me the son was open for some contact.” She trusted that her neurology registered the necessary information about the therapeutic system.
Videos and audiotapes of her seminars capture Satir’s genius better than anything she wrote, causing some students of family therapy to conclude, falsely, that she was soft on theoretical understanding. But, if pressed, she could easily rattle off abstract descriptions of systemic patterns. Her preference, however, was for simple language based on experiential observations.
There are, no doubt, charismatic and even mystical elements in Satir’s work—not to mention her skills as a stand-up-comic lecturer. Her own explanation for her personal power was that she was “congruent,” i.e., all her internal parts (images, sounds, words, feelings) worked together to support her external senses. A strong feature of her work was always to assume that everyone’s intentions were positive, no matter how awful the behavior. But Satir’s real power was her ability to work in many styles at once. Her sessions incorporated essential elements of strategic, structural, systemic, intergenerational, and experiential family therapy into a distinctive whole, in which her intuitions found their full play. Satir saw a cognitive approach to self-differentiation as insufficient, believing that meaningful change meant involving the whole person, reaching out to him or her on as many levels as possible.
Like a strategic therapist, she emphasized obtaining specific descriptions of the family’s presenting problem from family members. But she insisted that the presenting issue itself was seldom the real problem; rather, how people coped with the issue created the problem—a novel idea when she first presented it, as were her insights into how low self-esteem engendered peculiar, unbeneficial behaviors and relationships. A master of the strategic art of reframing, she incorporated in her work the structuralists’ insistence upon giving people an experience of change within the therapy hour, believing words change people only if they’re supported by the full experience of what the words point out.
Through techniques like family sculpting, she got people to enact their interactional difficulties, to give a clearer picture of exactly what was going on. But in addition to her concern with the here and now, she recognized the enormous influence of people’s experiences in their families of origin.
Summing up her view of how therapy works, Virginia Satir said, “It is simply a question of life reaching out to life. As a therapist, I am a companion. I try to help people tune into their own wisdom. Of course, all this doesn’t fit much of a psychotherapeutic theory.”
6. Albert Ellis
Albert Ellis is credited (at least he credits himself) with inventing cognitive-behavioral therapy (CBT), the most widely practiced and popular of all psychotherapy approaches today. By his own lights, he beat Aaron Beck, the “other” inventor of CBT, to the punch by a few years.
Both Beck and Ellis departed radically from the dominant psychoanalytic approach by asserting that childhood events were largely irrelevant to the emotional problems of adults, and focused instead on changing the self-defeating beliefs (usually automatic) that kept people stuck in their own emotional morass. Ellis maintains that his version of CBT, called Rational Emotional Behavior Therapy (REBT), differs from Beck’s because it isn’t just a clinical approach, but a realistic and rational philosophy of life, based on unconditional acceptance of oneself, of others, and of the world as it really is.
The huge popularity of CBT—and that of REBT—owes much to Ellis’s unflagging genius for self-promotion. The perennial bad boy of psychotherapy, he’s achieved a mix of fame, cultlike worship, notoriety, and grudging respect as the revolutionary-in-chief for the new paradigm. It’s hard, in fact, to separate REBT entirely from the Ellis phenomenon itself—manifested in countless profanity-laden, highly entertaining lectures, demonstrations, interviews, and weekly, open-therapy workshops he’s held for about four decades at the Albert Ellis Institute, which he founded in New York City. (Currently, Ellis is involved in a bitter legal dispute with the institute’s trustees about his compensation and health care benefits. They want him out, but in this contest, the smart money is on the deaf, stooped, medically frail, 93-year-old warrior, still unvanquished after all these years.)
Not hindering Ellis’s fame is the fact that he never suffered much from writer’s block. In the past half-century, he’s produced 54, 65, or possibly 75 books (accounts vary), 600 or 700 articles, and dozens? hundreds? thousands? of pamphlets, making him an unexcelled propagandist for his own invention.
Ellis drew his basic idea for a therapy from a source that had given him some comfort early in life—the 1st-century stoic Greek philosopher Epictetus, whose signature aphorism was, “We are disturbed not by events, but by the views we take of them.” Basically, says Ellis, we don’t suffer from depression, anxiety, panic, horror, self-loathing, or rage because of the bad things that happen or have happened to us in the past, but because of the false beliefs we unconsciously carry that become activated when misfortunes strike.
These beliefs can be reduced, he says, to three internalized commandments: 1. I must be perfect and successful at all times, or else I’m a worthless failure—an attitude that leads to depression, self-loathing, and despair. 2. People I care about must love and admire me completely at all times, and if they don’t, they’re “completely rotten and deserve to be blasted straight to hell”—a pattern of thinking that opens the way to “anger, fury, rage, genocide and, maybe, atomic holocaust.” 3. The world must always treat me well and give me exactly what I want when I want it—a belief that can create “depression, a low tolerance for life’s inevitable frustrations, laziness, and self-pity.”
In the Ellis canon, “rational self-acceptance”—the primary goal of REBT—rests not on our belief in our own essential worth as human beings, or on the fact that at least our therapist likes us, but on the fact that we’re alive. How does a human being achieve rational self-acceptance? By hard, hard work, that’s how. REBT isn’t for wimps or goof-offs, at least as Ellis describes it. The therapist relentlessly pursues you with questions aimed at rooting out your mistaken assumptions. Do you think you’re depressed because your boyfriend left you? Nope. It’s because of your underlying, grandiose belief that if you aren’t totally loved all the time, you’re worthless. And what evidence do you have for believing that you’re absolutely worthless unless somebody loves you? None. Clients are given coping statements or mantras and then, says Ellis, “you go over the mantra two thousand times very strongly, until you begin to believe it.”
Ellis and his method have been criticized for being superficial, simplistic, overly rationalistic, and dogmatic. Still, there’s something bracing and appealing about his vision of tough love that makes you want to laugh out loud. “Practically all individuals have strong innate and learned tendencies to act like babies all their lives,” he notes. Well, yes indeed!
7. Murray Bowen
Murray Bowen developed theories and invented terms now used, or at least known, by every family therapist practicing in America. His concepts of differentiation of self, emotional systems, triangles, emotional cutoffs, the family-projection process, sibling positions, and the multigenerational-transmission process have been woven into the fabric of the field. “Bowen was the intellectual beacon for everyone who was first trying to understand the family,” says Braulio Montalvo, who, with Salvador Minuchin, helped create structural family therapy in the early 1960s. “Almost every major concept in family therapy can be traced back to him. He taught everybody.”
Bowen did more than give intellectual legitimacy to the scruffy, make-do empiricism of family therapy. In large part, he created the field’s intellectual scaffolding, giving it the conceptual structure that distinguishes it from all other psychotherapies. What set him apart from other pathbreakers in the field was his determination to forge a new science of behavior—an overreaching natural systems theory that would be a comprehensive set of interlocking principles accounting for the entire range of human behavior and its evolutionary origins.
Said Robert Aylmer, a Bowen student: “Bowen was the first to realize you can’t translate the individual psychoanalytic concepts into the language of families, and the first to see the family as a structure in itself, which had its own wiring.” The family wasn’t, as previously believed, just a collection of mutually influential but separate psyches living together under the same roof. Rather, the submerged ebb and flow of family life, the simultaneous push and pull between family members, both for distance and togetherness, was the driving force underlying all human behavior. While Bowen didn’t invent systems thinking, he was the first to conceptualize the family as a natural system, which could be fully understood only in terms of the fluid but predictable processes between family members.
Unlike most family or individual therapists, Bowen conceived of personal growth and family interaction as part of an indivisible whole, and he created a therapy that involved both the self of the individual and the multiple relations in the family. He introduced a form of family therapy based on one family member’s researching and coming to terms with his or her own family of origin. Finally, Bowen gave family therapists a new way to know themselves. Said Carl Whitaker: “He transformed the psychoanalytic process of finding yourself into something particularly appropriate for family therapy. He showed family therapists a way they could look at themselves and their own lives, analogous to Freud’s self-analysis.” Bowen, alone, made it a critical point that therapists differentiate themselves from their own families before trying to help others do the same.
Bowen’s ideas have been used to improve the functioning of businesses, religious congregations, and other organizations, applied to ethical, cultural, economic, and gender issues, and synthesized with object-relations and other psychodynamic models. But these variations from his orthodoxy gave him no pleasure. Toward the end of his life, he went so far as to dismiss family therapy as an “evolutionary misadventure,” a mere grab bag of marketable new therapy techniques.
For Bowen, therapy was of a single cloth with his entire theory; tear out this or that piece as a “technique” and the whole tapestry became a tattered rag. “He wasn’t very happy with what most of us were doing,” said Philip Guerin, a former student of Bowen’s. Yet it was his very devotion to pure theory that made it possible for him to give so much to so many.
In 1975, Bowen summarized the fundamental insight from which his theories evolved: “Far more human activity is governed by man’s emotional system than he has been willing to admit, and there is far more similarity than dissimilarity between the ‘dance of life’ in lower forms and the ‘dance of life’ in human forms.”
Not a flattering idea, perhaps, but an idea that has proven tremendously fruitful.
8. Carl Jung
Carl Jung lit his farts on camping trips, danced with tribal people in Africa, built a stone tower with his own hands, socialized with his patients, and installed his mistress in his house (breaking his wife’s heart). He was unafraid to delve psychologically into mysticism, the occult, alchemy—anywhere he thought he could find truths. Without him, there’d have been no Joseph Campbell or the legions of myth-minded, spiritual authors whose ideas have found their way into many aspects of contemporary psychotherapy. Some think of him as the first manifestation of the therapist-as-rock-star because he had groupies and often seemed more like a guru than a therapist. But Jung originated the basic form of psychotherapy still practiced today in most fields: unlike Freud, he faced his patients, talking, consoling, taking their ideas seriously as they sat across a table. “I realized,” he wrote, “that one gets nowhere unless one talks to people about the things they know.”
It was Jung who first argued that we possess male and female aspects (animus and anima), as well as an unacknowledged, forbidding region, which he called the Shadow. He introduced the concepts of “introvert,” “extrovert,” “synchronicity,” and “the complex.” As family therapists one day would emphasize, he was less interested in what stage of childhood his patients were stuck in than how they were evolving in the present. For Jung, the unconscious was not Freud’s forbidding “id,” but a sea of meaningful, resonant symbols, which cut across cultures and historical eras. He believed that “individuation”—a marriage of the conscious and the unconscious parts of our being that reconciles our opposite character traits—was the highest goal. And it was Jung who developed the radical idea, explicated in our era by James Hillman, that neuroses and other psychological problems should be recognized not only as symptoms to be cured, but as messages from the unconscious that, if addressed with insight, point the way to a more fulfilling life.
Jung was the first psychoanalytic thinker to attempt a means of understanding collective human behavior. He believed that individual character flowed from an ancient collective pool of myths and archetypes: humanity’s age-old symbols swimming in what he postulated was a “collective unconscious.” “Although we human beings have our own personal life,” he wrote, “we are yet in large measure the representatives, the victim and promoters of a collective spirit whose years are counted in centuries.”
He affected countless people who’ve never entered a consulting room through the influence of his writings on the founders of Alcoholics Anonymous. The movement’s hugely successful and much-imitated 12-step program is largely based on his ideas.
No family therapist would disagree with his contention that “in the great crises of life, in the supreme moment when to be or not to be is the question, little tricks of suggestion do not help. Then the doctor’s whole being is challenged.” And therapists of every kind recognize a truth that Carl Jung was the first to articulate: “The most terrifying thing is to accept oneself completely.”
9. Milton Erickson
Despite everything that’s been written about Milton Erickson and the diligent efforts of so many to understand just what he did in therapy and why it worked so remarkably well, an air of mystery surrounds his work even now. Shortly after Erickson’s death, his 20-year student Jay Haley said, “Not a day passes that I don’t use something that I learned from Erickson in my work. Yet his basic ideas I only partially grasp.”
The image of Erickson that’s emerged in the field is that of a therapeutic wizard possessed of an overwhelming personal power. “He wasn’t the kind of person you’d just sit down and chat with,” recalls Jeffrey Zeig. “He was consistently working, consistently being Milton Erickson, which entailed having the most profound experience he could with whomever he was sitting with. In that sense, he was constantly hypnotic, constantly therapeutic, constantly teaching.”
Perhaps this was because Erickson’s physical state necessitated the complete focus of all his faculties. Dyslexic, tone deaf, color blind, prone to vertigo and disorientation, stricken with polio at 17 and again at 51, he spent the last 13 years of his life (the period in which many of his well-known students first met him) painfully confined to a wheelchair. As he tried to model the flexibility and subtle verbal methods he’d spent a lifetime developing, he did so with partially paralyzed lips and a dislocated tongue. Yet, as Haley said, “the man worked 10 hours a day, six or seven days a week doing therapy. . . . Every weekend, he was either seeing patients or on the road teaching.” Zeig adds: “The thing that was so impressive about Erickson was the time and energy he was willing to put out. Once he took somebody as a patient, he’d, literally, do anything he possibly could to help that person. When you were a client of Erickson, you just felt he was totally focused on you.”
Erickson spent a half-century developing an enormously subtle therapy of multileveled pattern recognition that was almost totally at odds with the mainstream therapies of his day. “Maladies,” Erickson said, “whether psychogenic or organic, follow definite patterns of some sort, particularly in the field of psychogenic disorders. A disruption of this pattern can be a most therapeutic measure, and it often matters little how small the disruption is, if introduced early enough.”
He discovered that most of the “rules” of life prescribing human limitations were arbitrary beliefs, not facts. His study and mastery of hypnosis taught him that altered mental states and trance were very much a part of everyday functioning. “This understanding,” wrote Ernest Rossi, “formed the underlying principle of his later studies of psychopathology as well as for his development of the naturalistic and utilization approaches to hypnotherapy.”
Such insights were fundamental to Erickson’s approach, but he sought no definite theory to pass on as a legacy. “Erickson has no set method,” Haley noted. “If one procedure doesn’t work, he tries others until one does. That’s what he emphasized to his students, advising a stance of heightened receptivity uncontaminated by formulaic preconceptions.” Erickson put it this way: “I don’t attempt to structure my psychotherapy except in a vague, general way. And in that vague general way, the patient structures it . . . in accordance with his own needs. . . . The first consideration in dealing with patients is to realize that each of them is an individual. . . . So in dealing with people, you try not to fit them into your concept of what they should be. . . . You should try to discover what their concept of themselves happens to be. . . . It isn’t the amount of time. It isn’t the theory of therapy. It’s how you reach the personality by saying the right thing at the right time.”
Further words of wisdom from Erickson: “Trust your unconscious. It’s a very delightful way of living, a very delightful way of accomplishing things.” And: “Don’t try to use somebody else’s technique. . . . Just discover your own.”
10. John Gottman
Throughout the 1980s and 1990s, in a specially outfitted studio apartment in Seattle that reporters nicknamed the “love lab,” mathematician-turned-psychologist John Gottman videotaped ordinary couples in their most ordinary moments—playing solitaire, chatting, kissing, disagreeing, watching TV, cooking dinner, joking. Sometimes Gottman asked them to discuss an area of conflict while monitors strapped to their chests recorded their heart rates, or he sat them on spring-loaded platforms to record fidgeting. He studied newlyweds, abusive couples, people who shout, and people who never raise their voices. Using an elaborate coding system, he tracked flickering facial expressions, sighs, clammy hands, rolling eyes. He followed couples for more than two decades to see who got divorced, who established parallel lives, and who stayed together (happily or not).
Then Gottman translated his data into numbers. He found he could predict a divorce with 91-percent accuracy by analyzing seven variables during a couple’s five-minute disagreement. (Whether his average is better than the town gossip’s has yet to be studied.) These discoveries made John Gottman famous. Many in the field now believe that most of what we know about marriage and divorce comes from his work.
Examining more than 3,000 couples, Gottman discovered that most of them fought, and that even the most happily married of them never resolved 69 percent of their conflicts. What was crucial to the longevity of a marriage, he learned, wasn’t whether a couple fought, but how.
Among couples whose marriages survived well—the “masters of marriage,” as Gottman and his colleagues call them—wives raised issues gently and brought them up sooner rather than later. Neither husbands nor wives regularly became so upset with each other that their heart rates rose above 95 beats a minute, and these couples broke rising tension with jokes, reassurance, and distractions. In Gottman’s study, 80 percent of complaints came from wives, but successful husbands didn’t play king or cross their arms in response. And most notably, “master” couples made at least 5 positive remarks or gestures toward each other for every zinger during a fight. In calmer times, their positive-to-negative ratio was an astounding 20 to 1. “Masters of disaster” couples were pretty much the opposite.
Gottman’s research showed that it wasn’t only how the couple fought that mattered, but how they made up. Marriages became stable over time if the couple learned to reconcile successfully after a fight. Partners heading for divorce responded to each other’s bids to clear the air only 33 percent of the time, while the happy couples’ response rate was 80 percent.
In 1994, Gottman and his wife, Julie Schwartz Gottman, a clinical psychologist, combined their expertise to fashion a science-based couples therapy. They began leading advanced training for therapists in 1998. By 2004, 4,000 couples had gone through their workshops or clinic. Two years later, more than 3,000 therapists had taken a basic training workshop with them, 65 had been certified, and 600 more were well on their way to certification in the Gottman Method Couples Therapy—a mix of classic therapeutic skills and scientific dispassion.
Research indicates that therapists using this approach can decisively stop their clients from what the Gottmans call “The Four Horsemen of Marital Apocalypse”—contempt, criticism, defensiveness, and stonewalling. More than 30 pen-and-paper questionnaires are methodically administered to each partner before therapy begins. Videotaping and heart-monitoring are standard parts of the therapy. The dispassion, structure, and authority of the approach eases and contains the discouragement and chaos often generated by couples in trouble.
Quantum physics has proven to all the sciences that the observer, no matter how neutral or objective, acts upon what’s observed. It’s still too early to know how much the couples of Gottman’s “love lab” were affected by Gottman himself and by being research subjects. Replication by others will decide the Gottman Method’s ultimate effectiveness, and it’ll take several years of such replication to garner further useful data. Results so far are promising, but at this stage, we must leave it for time to tell.
Richard Simon, PhD, founded Psychotherapy Networker and served as the editor for more than 40 years. He received every major magazine industry honor, including the National Magazine Award. Rich passed away November 2020, and we honor his memory and contributions to the field every day.