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For over 50 years, psychotherapy integration has been the subject of books, research articles, conferences, and much debate. Many scholars have put forth compelling arguments and effective treatments steeped in integrative thinking, and some have recently written books that propel integration further by elucidating the underlying change processes that occur across all of psychotherapy (e.g., Smith, 2018).
Nevertheless, relying on comprehensively integrative models of psychotherapy remains largely unpopular, both among scientific communities and training programs, in which therapeutic monoliths remain commonplace (Levy & Anderson, 2013), and among clinicians who most often practice from a perspective of technical eclecticism (Zarbo et al., 2016).
What has prevented the psychotherapy community from adopting a universal model of how psychotherapy works? Below I outline four ways in which our human cognitive biases may interfere with acceptance of a comprehensive paradigm of psychotherapy.
1. “What I do works, and people get better, so why change?”
We like to believe that we have some control over the outcomes in our lives and those of our clients. Many of us became clinicians because we wanted to help people, and it is incredibly self-affirming when we see our clients improve. However, we are constantly subject to the illusion of control, and our egocentrism makes it easy to believe that we are having an impact when we are not.
Thus, we notice illusory correlations in therapy and further mistake these correlations for evidence of a direct effect our interventions have on our clients. We are left believing that “my school of thought and repertoire of interventions are the reason my clients improve,” and consequently have little motivation to explore other ways of treating patients and no need for deeper and more accurate causal explanations for why our clients change. We remain satisfied in our belief that most of our clients improve, and in no small part due to our particular expertise. Unfortunately, we are shockingly bad at estimating how well we are doing as clinicians (Walfish et al., 2012), and our therapeutic interventions actually only explain a small amount of why people improve in therapy (Lambert & Barley, 2001).
2. “The evidence supports my way of thinking, and I want to be evidence-based.”
Ever since the first meta-analysis of psychotherapy outcome showed empirically that psychotherapy works (Smith & Glass, 1977), being empirically minded has been important to the therapeutic community. Countless research articles are now available that support our preferred therapeutic orientation. In fact, we are likely to be most familiar with the research base that uniquely supports our approach to treatment and oblivious to research evidence that supports other modalities. As scientists, we might conduct research on our treatment approach and quite often seem to find the results we hypothesized (read: were hoping for).
However, our allegiance to a given treatment approach leads us, in subtle ways, to ensure that we will find what we are looking for through the design of our studies and interpretation of our data. Similarly, we “see” evidence of our therapeutic mantras in our work with our clients, whether it be the client’s cognitive distortions or unconscious defenses, and overlook evidence of those aspects of the mind that do not fit into our therapeutic framework. We may even seek out clients with problems most conducive to our specific way of thinking and refer others with difficulties that are harder to explain. Thus, our training and experience in a specific approach to treatment may blind us to the efficacy of other approaches and keep us from seeing the benefit of a common understanding of therapeutic change; we remain prisoners of our own experience.
3. “I don’t have time to learn a new way of thinking,” or “If it ain’t broke, why fix it?”
We are all strapped for time. Being asked to learn a new way of thinking in our profession requires a pretty convincing argument to be worth the added effort. Furthermore, even if the argument is convincing—say, that an integrative treatment approach may produce more change in one’s clients or that an understanding of psychotherapy convergence may advance research on how the mind works—we tend to be conservative in our willingness to revise our beliefs and continue to put our energies into maintaining the approaches we have already spent years of training learning because to do otherwise would feel like a waste. We produce theoretical models of human behavior and write treatment plans for our clients, but then find ourselves resistant to updating these even when the data or our clients give us ample reason to. We are, after all, creatures of habit.
4. “Even if I wanted to, considering 'those' types of treatment or aspects of human existence is not OK among my professional peers.”
Even (and sometimes especially) in our professional circles, the powers of peer pressure persist. Our membership in groups such as graduate programs, professional societies, and private practices imbues us with a preference for those who are like us and often, unfortunately, a dislike of those are who are not. We often see schools of psychotherapy as in conflict with each other, competing over the same turf for federal grant monies, client referrals, and professional clout.
This belief in the “zero-sum game” of psychotherapy orientations leads us to downplay the credibility of other ways of thinking and to view those across the aisle as uninformed or misguided, rather than recognizing our own personal and often emotional (rather than scientific) reasons for holding on to what we know. We might also find ourselves censoring our internal struggles regarding the supremacy of our form of therapy and our temptations to think and practice more integratively in order to “fit in” with our professional peers. All of this may leave us intractably enmeshed in our own tribe of therapy and hopelessly embattled in discrete psychotherapy camps.
So, what do we do?
Is there really no way out of the maze of our own cognitive biases? Although the road to broad acceptance of a universal explanatory model of psychotherapy will remain a bumpy one, we can ease and accelerate the process by taking stock of the cognitive biases that cloud our thinking. Being mindful of the implicit ways in which our minds “protect” us from the potential “dangers” of psychotherapy convergence, and actively working to counteract these biases, is crucial.
The psychotherapy community has already taken strides in this vein, such as preregistering research trials to prevent expectancy biases. Training integrative approaches to psychotherapy at the start of graduate training programs might also prevent many of the ingrained biases we have towards convergent ways of thinking. As long as we are vigilant about the obstacles we ourselves erect, we may soon see the dawn of a new era of psychotherapy.
What cognitive biases have I myself fallen prey to in writing this post? I would love your comments below!
—Benjamin N. Johnson, M.S.
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References
Lambert, M. J., & Barley, D. E. (2001). Research summary on the therapeutic relationship and psychotherapy outcome. Psychotherapy: Theory, Research, Practice, Training, 38(4), 357.
Levy, K. N., & Anderson, T. (2013). Is clinical psychology doctoral training becoming less intellectually diverse? And if so, what can be done? Clinical Psychology: Science and Practice, 20(2), 211-220.
Smith, J. (2017). Psychotherapy. Springer International Publishing. http://link.springer.com/10.1007/978-3-319-49460-9
Smith, M. L., & Glass, G. V. (1977). Meta-analysis of psychotherapy outcome studies. American Psychologist, 32(9), 752.
Walfish, S., McAlister, B., O'Donnell, P., & Lambert, M. J. (2012). An investigation of self-assessment bias in mental health providers. Psychological Reports, 110(2), 639-644.
Zarbo, C., Tasca, G. A., Cattafi, F., & Compare, A. (2016). Integrative psychotherapy works. Frontiers in Psychology, 6, 2021.
