Time for Consensus
My personal and professional mission, is to work towards overcoming the splintering of psychotherapy that has degraded our profession and shortchanged our patients. This was topic of a webinar I participated in on May 13, 2021 with Gregg Henriques, a prolific writer on meta-theory in psychology, and Marvin Goldfried, who co-founded SEPI, the Society for the Exploration of Psychotherapy Integration, almost 40 years ago. The webinar recording, moderated by Michael Mascolo, is available for SEPI members (Join for $59/year) on their website, www.sepiweb.org, where you will find many more excellent resources.
What was most surprising about the webinar is that we all agreed! Here are some points of agreement:
- It’s time to end 40 years of endless discussion and arrive at a consensus.
- There are a few well known principles, central to the action of psychotherapy, and they aren’t particularly controversial.
- Each school of therapy has invented its own vocabulary and ways of explaining the same principles, providing richness of thought but making it hard to cross from one orientation to another.
- Rather than following a single method Clinicians need to focus on finding the best match between technique, patient, and the specific situation.
So what’s the problem?
Why are so many therapists still following the traditional, but limiting and inefficient, path of learning a single modality and, only later, daring to branch out into other techniques and ways of thinking? Here are some possibilities:
- The leaders and teachers are older and set in their ways.
- Competition between schools emphasizes difference rather than consensus.
- Therapists tend to cling to an organization for security, community, and referrals.
- Academic advancement is not helped by breadth of thought or universality.
- Principles have not previously been formulated in an accessible and user-friendly package compatible with all schools of therapy.
In this post, I’ll focus on the last item on the list. Goldfried (2019), in an article on why we have not arrived at a consensus, writes that we are missing a “common core,” “a body of knowledge, built on past research, where there exists a consensus among researchers.” But we do have such a core. What seems to have prevented our field form adopting it is the fact that seeing the core requires looking beyond our field and linking with work from evolutionary biology and neuroscience.
Below is a diagram of a path for arriving at a core of knowledge capable of bringing diverse schools of therapy under one “big tent.”
The pathway starts by narrowing our view to precisely what psychotherapy aims to treat. As discussed in TIFT #11, this leads to identifying Entrenched Maladaptive Patterns (EMPs), as the basic units of pathology treatable in psychotherapy. From there,we bring in evolutionary biology, suggesting that EMPs have in common that they generally represent protective responses to circumstances appraised as threats. Next, reaching out to neuroscience, we adopt a working hypothesis that neurophysiological mechanisms of change applicable to the learned fear paradigm can be generalized to EMPs. The well researched known mechanisms responsible for attenuation of learned fear responses are Extinction and Memory Reconsolidation.
Next, we examine the conditions required for Extinction and for Memory Reconsolidation and make the remarkable discovery that the three necessary and sufficient elements required for modification of existing patterns correspond quite closely to what each school of therapy already knows. With this joining of psychology and outside science, we bring together the branches and foliage of current schools of therapy with the trunk and roots of a common infrastructure that belongs to all therapies. I’ll repeat the fundamental requirements for change from TIFT #11:
Clinical Requirements for Change:
- Activation of old maladaptive response patterns with affect, required for both Extinction and Memory Reconsolidation, the two known mechanisms for change in established patterns (for example through exploration and empathy).
- Exposure (in temporal juxtaposition) to new information that contradicts the old pattern and generates prediction error as required for both Extinction and Memory Reconsolidation. (accomplished, for example, through interpretation, cognitive and experiential exercises, and within relationship).
- New learning, cognitive or experiential, offering healthier response patterns and narratives, where not previously acquired (multiple sources).
Once again, I am grateful for Dr. Goldfried (personal communication) for the following list of terms taken from diverse therapies to capture the clinical juxtaposition of old (maladaptive) patterns with new information:
“reflective functioning,” “cognitive restructuring,” “observing ego,” “wise mind,” “self-observation,” “metacognition,” “decentering,” “witnessing,” “mindfulness,” “insightful”
I hope you appreciate how strongly these words suggest that every therapy includes the same three elements leading to change. The differences between “incompatible” theories are mostly due to the language and constructs invented by some very wise people to describe the same phenomena, but in the absence of an agreed upon core of knowledge. Sometimes they are talking about different parts of the elephant and sometimes they have different names for the same parts. But as you observe what’s happening in your sessions, you will see yourself working to support the three conditions above (plus the Four Facilitative Factors listed towards the end of TIFT #11).
That’s how understanding the common infrastructure is, in my view, not so controversial and gives us a simple and relatively accessible core of knowledge with which me might finally breach the silos that divide the schools and orientations of psychotherapy.
Jeffery Smith MD
Goldfried, M. R. (2019). Obtaining consensus in psychotherapy: What holds us back? American Psychologist, 74(4), 484–496. https://doi.org/10.1037/amp0000365
Jeffery Steven Smith & Benjamin Johnson. The Affect Avoidance Model: An Integrative Paradigm for Psychotherapy (Major Revision, Final). ResearchGate.org, June 2018
Jeffery Smith MD
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