Toward a Common Core of Psychotherapy

(This blog summarizes a recent video series shared here and here.)

Source: Goldfried, Smith, Henriques on YouTube

Does psychotherapy have a common core? Currently, the field has been largely unable to identify one. To understand why, we shift the question for contrast and ask: “Does modern Western medicine have a common core?” One can answer that the question is largely a “yes.” Modern medicine is based on the science of human biology, which includes genetics, physiology, and anatomy. In addition, modern medicine includes the science of pathophysiology and medicinal healing. Put in simpler terms, modern medicine has a common core that is centered around the treatment of “broken biology” that causes harm. This is the essence of the bio-medical model that defines the core of modern medicine. Although there is much debate and disagreement about all the specifics—including the idea that medicine should be more biopsychosocial in its orientation toward health—there is, nonetheless, a basic, core identity of the medical profession that can be framed in these terms.

When we look to psychotherapy, however, there has been virtually no core agreement on what it fundamentally is about. In a seminal American Psychologist article (Goldfried, 2019), Professor Marv Goldfried, a co-founder of the Society for the Exploration of Psychotherapy Integration, lamented that the field still lacked a core center of agreement and invited scholars, practitioners, researchers, and theorists to focus their attention on developing a common core of agreement.

This call recently led to a series of panel discussions called Advancing Psychotherapy Integration by Creating Common Ground. In these discussions, Goldfried was joined by Dr. Jeffery Smith (leader of the Special Interest Group on Convergence), Dr. Gregg Henriques (SEPI President-Elect, founder of the Unified Theory of Psychology), and (in Part I) Dr. Michael Mascolo (Founder of Creating Common Ground). Over the course of three hours of dialogue (see here and here), the interlocutors ended up finding strong agreement in four key areas pertaining to the:

1. problems that psychotherapy treats
2. the processes of change
3. the basic mechanisms that link the problems with the processes
4. the principles that guide the therapist and treatment and are consistently associated with good outcomes

The Problems Psychotherapy Treats Can Be Framed as Entrenched Maladaptive Patterns

Although counseling can refer to many things, the panel agreed that it might be useful to frame the systematic therapeutic healing elements of psychotherapy in terms of treating Entrenched Maladaptive Patterns. Entrenched refers to the fact that the problems are difficult to adjust to and clinically significant. Maladaptive patterns refer to:

• psychological behavior can be framed in terms of attempts to adapt to the situation and learn from it
• many patterns can emerge whereby the consequences result in harmful dysfunctional patterns that are distressing to the individual and that interventions involve developing new, more adaptive patterned ways of responding and being in the world.

The Process of Change Involves Awareness, Acceptance, and Action

In his “unified approach” to psychotherapy (Henriques, 2011), Henriques has long argued that three general processes can be identified, that of fostering awareness and acceptance and engendering action toward new ways of being. This frame is similar to the stages of change developed by Prochaska and DiClemente (1983), which many see as a transtheoretical model for the process of psychotherapy. Goldfried similarly developed a simple but profound schema that lists four steps towards more adaptive functioning, which go from unconscious incompetence to conscious incompetence, to conscious competence, and finally to unconscious competence. This refers to how people come into therapy unaware and unable to function in the domain of concern, how they obtain awareness but still struggle, then they learn new skills with deliberate practice and then finally internalize the new way of being automatically.

The Core Mechanism of Change Involves New Learning

If the problems that psychotherapy addresses are Entrenched Maladaptive Patterns, then what is the mechanism that allows for patients to change? The short answer is new learning. The longer answer is that a context needs to be developed so that new core emotional responses to difficult, triggering stimuli can be cultivated. In his work on highlighting the core mechanisms that underlie change, Jeffery Smith (2017) emphasized the productive bridge between basic research in the behavioral and neurosciences that provide a frame for how EMPs first get learned and how new learning can be achieved. Specifically:

1. new learning is mediated by LTP (Long Term Potentiation)
2. extinction, which was described by Pavlov, cortical learning that takes place while the old pattern is active leads to inhibitory signals being sent to the limbic areas where response patterns are triggered, inhibiting the maladaptive response,
3. memory reconsolidation, which activation, with affect, of the old pattern, when juxtaposed with exposure to new and surprising information, results in temporary volatility of the old memory structure and permanent updating in accordance with the new information.

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This more technical description grounded in the neuro and behavioral sciences actually line up with what are called “corrective emotional experiences” in the therapy. Basically, it involves encountering the triggers that usually engender a maladaptive avoidance or defense, and instead of sitting with the feeling until a new feeling and narrative are developed in relation to it. By mapping EMPs with the corrective emotional experiences in a process change, a general outline of adaptive change emerges, which can be seen here, as developed by Goldfried and relayed in the discussion.

competence

Source: Goldfried

The Core Principles that Facilitate Effective Change and Generate Good Outcomes

Many scholars and therapists, including Goldfried, Smith, and Henriques, have argued that psychotherapy can and should be effectively framed in terms of principles that foster effective change and good outcomes. For example, in a seminal article, Goldfried (2019) emphasized that principles were the right level of abstraction to engender agreement, operating above the level of specific research findings, but below theoretical orientations guided by specific schools of thought. He proposed five mid-level principles that should serve as guideposts across the process of therapy:

1. Expectation and motivation that therapy will help
2. Presence of an optimal therapeutic alliance
3. Helping patients become better aware of themselves and their world
4. Encouraging corrective experiences
5. Facilitating ongoing reality testing (working through and maintenance)

Conclusion

As Goldfried (2019) notes, the field of psychotherapy has been around for more than 100 years, yet it still lacks agreement about what psychotherapy is and what it treats. As leaders in the field, we found that perhaps the time is right for the specification of a common core of psychotherapy defined in terms of the problems, processes, mechanisms, and principles that can effectively capture the work of therapists across the bona fide orientations and approaches. If this is so, we may be able to significantly advance the field in the next century.