Embarrassing problems for the field of psychotherapy

I N V I T E D P A P E R

Embarrassing Problems for the Field of PsychotherapyÄ

Alvin R. MahrerUniversity of Ottawa

A case is presented that the field of psychotherapy has some embarrass-ing problems that are collectively denied and that it is important for thefield to admit they exist so that steps can be taken toward their resolution.A provisional list of 11 problems is proposed, together with suggestedavenues toward solution. The invitation is to consider, revise, improve, andextend the list of embarrassing problems in a spirit of open debate anddiscussion to help advance the field of psychotherapy by enabling effortstoward resolution of these embarrassing problems. © 1999 John Wiley& Sons, Inc. J Clin Psychol 55: 1147–1156, 1999.

I am going to describe 11 problems that I believe are embarrassing for the field of psy-chotherapy, from its practice to its research, from its theory to its education, training, andprofessional status. But the problem is that these problems can be so embarrassing thatthe knee-jerk reaction is instant denial. Philosophers of science start wondering whethera field is heading for some foundational changes when the establishment reacts to embar-rassing problems with instant collective denial (cf. Bloor, 1991; Chubin & Hackett, 1990;Fuller, 1994, 1996; Paulus, 1989; Slife & Williams, 1995). But denial is apparently thefashion, even if the denial is collectively denied.

One way to deny that these are embarrassing problems is to react by saying: You arewrong. You are bad or mad for daring to say these are problems. Your case lacks theproper background, knowledge, and evidence. You are merely spewing personal opin-ions. You failed to prove those are problems. You are oversimplifying, distorting, over-stating. You cannot undermine what is known as true. We will find reasons for refusing topublish what you falsely claim are embarrassing problems.

Nevertheless, I will risk trying to describe some embarrassing problems for the fieldof psychotherapy. If you agree with any of these, then perhaps we can work toward

This article is based on an address on the occasion of receiving the 1997 Distinguished Psychologist Awardfrom the Division of Psychotherapy, American Psychological Association, at the annual convention, Chicago,August, 1997.Correspondence concerning this article should be addressed to Alvin R. Mahrer, Ph.D., School of Psychology,University of Ottawa, Canada K1N 6N5.

JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 55(9), 1147–1156 (1999)© 1999 John Wiley & Sons, Inc. CCC 0021-9762/99/091147-10

solving the problems, possibly along the lines I will briefly suggest at the end of eachproblem. If you disagree, then my invitation is to drop these problems from the list andadd what you believe are better embarrassing problems that stand out and ought to besolved.

These problems generally have been kept out of polite conversation. To give themthe attention they deserve, I am going to risk prejudicing my case by deliberately describ-ing each problem in a way that is guilty of charges of oversimplification, overstatement,overexaggeration, overdramatization, and overblown, unrealistic distortion.

1. The Field of Psychotherapy Is Reluctant to AdmitThere Really Is a Field of Psychotherapy

If a student wants to become a nurse or an architect or an engineer, many universitieshave schools or departments of nursing or architecture or engineering. But if a studentwants to become a psychotherapist, very few universities have a school or department ofpsychotherapy. Maybe there is no field of psychotherapy.

Or maybe universities are embarrassed about psychotherapy, so they first disguisethe term by using various code words such as case work, counseling, analysis, psycho-analysis, guidance, or behavior change, and then universities hide it deep inside lots ofschools and departments such as psychology, education, health sciences, social work,nursing, medicine, or religious studies. Maybe there is no field of psychotherapy.

Even when the student graduates or gets a license or certificate from some profes-sional body, the formal diploma or certificate rarely includes the wordpsychotherapy,nor does there seem to be a formally recognized specialty of psychotherapy in many ofthe psychotherapy-related professions (Paris, Kravitz, & Prince, 1986; Sales, Bricklin, &Hall, 1984).

Although a case can be made that there really is no field of psychotherapy, perhapsone part of a solution is for psychotherapy-related professions and educational institu-tions to acknowledge that some single term, for example, psychotherapy, is accepted asthe overall term that includes such things as case work, counseling, analysis, psychoanal-ysis, guidance, behavior change, and so on. This could make it easier for universities toadmit that they do offer identifiable training programs in psychotherapy, or whatever it isto be called. Perhaps another part of a solution is for universities and psychotherapy-related professions to use the word psychotherapy somewhere appropriate in their diplo-mas, licenses, and certificates (cf. Samuels, 1992). There can be other and better solutionsonce we admit there is a problem.

2. Lots of Professions Insist on Exclusive Ownership RightsOver the Field of Psychotherapy

Picture a gathering of all the psychotherapy-related professions and someone asking,“Who has a justified right to train psychotherapists?”. Psychologists would raise theircollective hand. So would social workers, nurses, and educators. The school of medicinewould raise its hand. So would schools and departments of pastoral studies, human rela-tions, rehabilitation, guidance, child development, family studies, philosophy, and manyothers. Furthermore, if pressed, they can all defend their right to provide the training andto set and enforce the standards of education and practice (Fox, Kovacs, & Graham,1985; Mahrer, 1987).

In many universities, essentially the same psychotherapy courses are taught in two tofive different faculties, schools, and departments, with slightly different course titles.

1148 Journal of Clinical Psychology, September 1999

And each profession awards the graduate with its own degree, so psychotherapists haveM.D. degrees, Ed.D. degrees, Psy. D. degrees, D.S.W. degrees, 5–10 different kinds ofPh.D. degrees, as well as 10–20 different kinds of master’s degrees in 10–20 differentkinds of faculties and schools.

Not only do so many faculties, schools, and professions know that they have thesupreme right to train psychotherapists, but they also know that they are to grant thelicenses and to wear the black robes of the judges who uphold the ethical standards. Sothere are licensing and ethical boards in psychiatry, social work, psychology, and eachprofession that proclaims exclusive ownership rights over the field of psychotherapy.

What is one solution? Picture a single composite field of those who share an identityas psychotherapy practitioners, theoreticians, researchers, and educators-trainers. Themore this shared-interest field comes about, perhaps there can be a diffusion in so manyof the long-standing, unpleasant antagonisms between most of the psychotherapy-relatedprofessions. Perhaps then it might be possible for this single composite field to bite thebullet and to work toward a single professional training program, a single degree, a singleset of standards, and a single overall body for the granting of licenses and registrationsand also for the setting and upholding of standards (Holt, 1965; Mahrer, 1992). Whateverthe solution may be, it probably helps first to admit that we have a problem here.

3. Psychotherapists Have Virtually No Subject Matter of Their Very Own

In general, plumbers have the field of plumbing largely to themselves, legal matters aretaken care of by lawyers, electrical things are the province of electricians, and architec-ture is done by architects. Medicine generally has mandate over the body, with somenegotiated understanding with dentistry over the teeth, optometry over the eyes, and soon. But pity the poor psychotherapists. They are still struggling to carve out a territory oftheir very own. Early on, they claimed the territory of lunacy, dementia, derangement—people who were out of their minds. Little wonder that the traditional term for what wenow call psychiatrists wasalienist. But even on this subject matter there were problems.One was that psychotherapists could not accomplish much with these people. Then otherprofessionals intruded with their social and community ideas, and a new breed of profes-sionals had all sorts of drugs and chemicals. Little wonder that psychotherapists wereforced to retreat into claiming ownership over the sheer labeling of these people, so theyinvented official nomenclatures of mental illnesses and diseases, and they claimed own-ership over doing research on the people who were sadly not their exclusive subjectmatter.

Psychotherapists then tried to own what they cleverly labeled as psychological orpsychiatric or personal problems, except that there was exceedingly stiff competitionfrom groups known as parents, physicians, priests and rabbis, social workers, bartenders,funeral directors, lawyers, guidance counselors, career counselors, family counselors,athletic counselors, personal counselors, astrological counselors, nurses, teachers, friends,and on and on. After more than a century, psychotherapists still have virtually no subjectmatter of their very own.

Perhaps one solution is to admit that we have trouble defining our territory, whateverit is, and to stop proclaiming our exclusive rights over a territory we cannot define.Maybe it is time to admit that other groups share our territory, whatever it is, and to leavethe problem of clarifying our subject matter in the hands of interested philosophers ratherthan clever lawyers. Maybe the nature of our subject matter will emerge by itself whenwe can divert our zeal to defend our undefined territory into a zeal for becoming far betterpractitioners, theorists, researchers, educators-trainers, and philosophers of science.

Embarrassing Problems for Psychotherapy 1149

4. Psychotherapists Try to Fix Problems That Are Mainly Unreal Fictions,Concocted Mainly by Psychotherapists

Some professionals fix a roof that leaks, a bone that is broken, a motor that won’t start.Psychotherapists are busy trying to fix things that are mainly unreal fictions, inventedmainly by psychotherapists. They repair such curiously fictitious things as a weak ego,dysthymia, lowered perceptual defense, inadequate self-other differentiation, identity dif-fusion, self-depletion, cognitive rigidity, a punitive superego, lack of autonomy, and hun-dreds of other things that can be seen only or mainly by psychotherapists.

I have trouble imagining an ego. I have never seen one. I would have trouble tellingthat an ego is weak or the wrong color or has holes in it. Something seems wrong if whatpsychotherapists fix almost no one but psychotherapists can see, and can see needs fix-ing. Something seems wrong if the problems that psychotherapists try to fix are mainlyunreal fictions, concocted mainly by psychotherapists.

Perhaps one solution is for psychotherapists to take a giant step down into the actual,simple, everyday world of real things that can be touched, known, seen, felt. The chal-lenge is to be able to point toward real things and to be able to say we can help bringabout these real changes in those real things (cf. Bateson, 1979; Garrett, 1996; Quine,1985; Rorty, 1991). If our work is with what we call problems or painful concerns ormental disorders, the challenge is to anchor them in a real world that real people cantouch, know, see, feel.

5. Psychotherapy Is a Pseudoscience of Nonexisting Unrealities,Measured With Rigorous Precision

Most scientists believe that if something is real, it can be measured. Psychotherapists arequixotically unique in their certainty that if they can devise a measure of it, then it mustof course be real. We have the idea backwards, but we are energetic at our pseudoscience.

We are convinced that there really are things like schizophrenia, altruism, introver-sion, conceptual schemata, egos, and hundreds of other things mainly because we havethousands of measures, scales, and tests, all of which are subjected to the highest rigorousstandards of science. Set our scientific measure-makers on the task, and they can provethe existence of schizophrenia, devil possession, elves and goblins, witches and war-locks. No problem. We have scientific measures.

While the emperor’s tailors are measuring the sleeve-length of the garment withimpeccable precision, psychotherapists are using rigorous measures to measure the emper-or’s ego defect. Both the tailors and our intrepid psychotherapists know that anythingmeasured with scientific precision must therefore be real. But the psychotherapists are onmuch safer ground. A little boy in the crowd can see that the emperor has no clothes. Justlet that little boy try to convince the crowd that the emperor has no ego! Psychotherapistsare still fooling the crowds by wrapping themselves in a pseudoscience of nonexistingunrealities, measured with rigorous precision. Our field is a public relations success story.

Perhaps one solution is to let go of the relatively fixed idea that if we can devise arigorous measure of something then the something must be real. If the urge to be preciseis to reassure ourselves that psychotherapy is indeed almost a science, then maybe a moreuseful search is for better ways of elevating psychotherapy into a science. A good begin-ning might be to bite the bullet and let go of our world of ephemeral unreality that wedoggedly try to measure scientifically, probably because of an initial mistake when “thepsychologist blandly undertook to build himself a science out of unrealities” (Kantor,1945, p. 151). If the urge is to give respectability to our high-level constructs and con-


cepts, notions and ideas, perhaps there are better ways than trying to devise precisemeasures of pseudoscientific unrealities.

6. Instead of Learning by Observing and Studying the Work of FinePsychotherapists, Students Are Supposed to Learn Howto Do Psychotherapy Without Observing and Studying

the Work of Fine Psychotherapists

Carpenters and plumbers and electricians apprentice themselves to competent carpentersand plumbers and electricians. Nurses and physicians learn their craft by observing andstudying competent nurses and physicians. Students can observe and study the work offine architects, engineers, painters, writers, singers, cellists, lawyers, and actors. It ispractically a requirement that students learn a guild, a trade, or a craft by observing andstudying the work of fine practitioners.

Try to imagine becoming a violinist without ever hearing a fine violinist. If psycho-therapists took over art museums, they probably would remove the actual paintings fromthe frames and replace them with brief reports telling about the paintings. Imagine havingsurgery by a surgeon who never saw another surgeon doing surgery. It is almostunthinkable—except in the field of psychotherapy. Psychotherapy is probably the onlyprofession that trains practitioners without having them spend 500 hours or even 5 hoursin mandated observation and study of fine practitioners doing what the students are to beable to do.

Perhaps one solution is for the education and training of psychotherapists to includea mandated number of hours of teacher-led observation and study of the actual work ofseasoned, competent, exemplary psychotherapists doing what the students are to learn todo. Picture a training program in which students learn both the working theory and meth-ods of psychotherapy as shown in the actual in-session work of fine practitioners.

7. Psychotherapists Are Licensed, Registered, Certified, and AccreditedWithout Having to Demonstrate That They Can Do Psychotherapy

Whether the psychotherapist is a psychologist, psychiatrist, social worker, or member ofany other psychotherapy-related profession, they usually have to pass a test to be licensed,registered, certified, or accredited. How many of these tests examine the candidate’sdemonstrated competence to do psychotherapy? I believe the answer is none (Fox, Kovacs,& Graham, 1985; Fretz & Mills, 1980), though there may be some exception. “Here isyour license. You pass.” “But I don’t know how to do psychotherapy!” “That’s not ourproblem. We just give out licenses. Next.”

I can picture a licensed, registered, certified, accredited practitioner suing a profes-sional board for issuing a license without proper examination of competence to do psy-chotherapy. Perhaps the board might in turn accuse the education and training programsthat were supposed to make sure the candidate was competent before swearing that all therequirements were met. On the other hand, lawyers for the education and training pro-grams might proclaim, “We educate and train physicians, psychologists, social workers,and similar types. We never promised to produce competent psychotherapists. Besides,psychotherapy does not legally exist in our education and training institutions!”

About the only ones who offer to provide competence in doing psychotherapy are thehundreds and hundreds of postgraduate training centers. They promise that graduates willbe competent in everything from psychoanalysis to client-centered therapy, from behav-ioral to Gestalt therapy. Although they have been around for as long as psychotherapy has


been around, and although they are exceedingly plentiful and have substantive programs(American Psychiatric Association, 1985; Lubin, 1962; Mahrer, 1992; Mayman, 1964;Rachman & Kauff, 1972), they are essentially outside the jurisdiction of both educationand training programs in university settings and professional licensing, registration, cer-tification, and accreditation boards.

Perhaps one solution is to make sure that those we license, register, certify, andaccredit to do psychotherapy actually meet sensible standards of competence in doingpsychotherapy (Mahrer, 1987). The task would be for education and training programsand professional bodies to accept serious responsibility for ensuring that candidates dem-onstrate the skills and competencies they are educated, trained, and accredited as havingacquired.

8. A Program to Train a Person to Do What PsychotherapistsDo Takes About Two or Three Days

Most masters programs take around 2 years to complete. Doctoral programs and intern-ships generally call for 5 to 7 years. Starting with the right person, a concentrated trainingprogram to enable the person to do what most psychotherapists do, and to be virtuallyindistinguishable from most psychotherapists, takes about 2 or 3 days (cf. Berman &Norton, 1985; Christensen & Jacobson, 1994; Durlak, 1979; Hattie, Sharpley, & Rogers,1984; Mahrer, 1996).

The right person is ready and willing to enact the role of psychotherapist after 2 or3 days of concentrated training. An ideal candidate is an actor whose next role is that ofa psychotherapist. For the methodologically minded, candidates may be set aside whohave been patients in psychotherapy or who have taken courses in psychotherapy.

Picture four to six actors who start by studying videotapes of sessions conducted byrelatively mainstream psychotherapists doing both initial and subsequent sessions. Theactors select which of the professional psychotherapists they believe they can more easilyplay and then carefully study two or three videotapes of those psychotherapists doingtheir work. The director is a psychotherapist who answers the actors’ questions so thatthey can more effectively play the role of psychotherapist.

Varying somewhat with the particular professional psychotherapist, the actors studyhow to carry out the role of psychotherapist, how to listen carefully and interestedly,when to talk and what to inquire about, how to convey concern and interest and under-standing, how to track and follow what the patient is saying and doing, how to keep thefocus on personal issues, how to value gradual improvement and change, how to enablethe patient to do most of the talking.

The next stage is actual try-out and rehearsal. Fellow actors play the role of patient,and for perhaps 4 to 6 hours the actors rehearse the role of psychotherapist, with thedirector-teacher helping to guide and refine what the actors do and how they do it.

By the end of 2 or 3 days of concentrated practice and rehearsal, the actors would prob-ably be, and perhaps could easily be, virtually indistinguishable from most professionalpsychotherapists doing most psychotherapies with most patients and using most criteriaof outcome success and effectiveness. They might have some trouble talking about theirsessions and their patients in the jargon that most psychotherapists can fluently use.

If this is a problem, then perhaps one solution is to work at elevating what psycho-therapists can actually accomplish in their sessions so that even trained actors wouldquickly and easily be conspicuously distinguishable from future psychotherapists whosehigh levels of competence and expertise also would be quickly and easily distinguishablefrom the competence and expertise of most current psychotherapists.


9. Most Psychotherapists Are Distinguished Mainly by Their Skillin Speaking Psychobabble

One of the main things that characterize psychotherapists and that distinguish them fromothers is their spouting psychobabble. They learn to say terms that give the illusion ofgenuine knowledge, of professionalism, of science (Illich, 1970; Schon, 1982). They areelite and specialized because they spout jargon terms like unconditioned positive regard,contingency control, transference, reframing, double bind, existential analysis, bioener-getics, phallic stage, archetype, multimodal therapy, systematic desensitization, cognitiveschema, catharsis, impulse control, avoidance conditioning, stimulus control, ego diffu-sion, countertransference, logotherapy, and attribution theory. Psychotherapists are dis-tinguished mainly by their using these terms with effortless ease, as if they knew what theterms meant.

Then they can speak in impressive paragraphs such as this, taken from a table ofrandom psychobabble phrases: “This client is characterized by free-floating anxiety in aborderline disorder, brought about by a traumatic childhood history of emotional abuse,lack of a stable support system, and inadequate cognitive development. Accordingly, thetreatment of choice is systemic therapy, with reframing of core conceptual schemata, toheighten self-efficacy in a supportive therapist-client alliance emphasizing positive regardand minimizing interpretive probing into stressful pockets of serious psychopathology.”The speaker may have no idea what he or she is saying, or may even secretly know thathe or she is playing the game of silly psychobabble, but if the speaker carries it off withprofessional aplomb, he or she probably can be accepted into the inner ranks of profes-sional psychotherapists.

Perhaps one solution is for psychotherapists to be distinguished much more by theirconcrete skills in accomplishing worthwhile actual changes, rather than by their fluencyin speaking psychobabble. Perhaps a related solution is to replace the psychobabble vocab-ulary, where the term is almost more important than the clarity of its meaning, with avocabulary where the meaning truly defines the term (cf. Hocutt, 1996).

10. The Results of Psychotherapy Research Have Essentially MadeNo Significant Differences on the Field of Psychotherapy

Psychotherapists are proudly indebted to their comrades who do research on psychother-apy. The field of psychotherapy looks respectable when there are serious researchersbusily dedicated to doing research on psychotherapy (cf. Maling & Howard, 1994; Moras,1994). The field can pass itself off as a science. Most approaches that seek to becomerespectable have their own researchers producing friendly studies on behalf of the approach.If anyone doubts that psychotherapy is truly a scientific field, put the doubter in the roomfilled with thousands of published studies.

Psychotherapists can be proud of their researchers because the researchers don’treally bother practitioners much. Every so often researchers grumble that practitionerspay little or no attention to their findings, and they are right. In general, the practice ofpsychotherapy is essentially undisturbed by whatever researchers do. The practice ofpsychotherapy probably would be insignificantly different if researchers had instead spenttheir time playing volleyball. Precious little, if anything, of what practitioners actually dowas given to them by researchers (Barlow, 1981; Edelson, 1994; Kiesler, 1994; Morrow-Bradley & Elliott, 1986). It seems that researchers have an earned status of being essen-tially irrelevant, except that they help make the field look respectable.

Perhaps one solution is for research to highlight the kinds of studies whose findingswould likely have practitioners lining up at the researchers’ doors. For example, research-


ers can place much more emphasis on studying the actual in-session process of psycho-therapy—on discovering what practitioners can do and how to do it—so that their actualin-session work is much better, much more effective, much more workable, and muchmore successful at accomplishing much more (cf. Elliott, 1983; Mahrer, 1996; Rice &Greenberg, 1984; Talley, Strupp, & Butler, 1994). When researchers can help discoverwhat to do in in-session work and how to do it, when researchers can discover howin-session work can be magnificently effective, practitioners would do far more shoppingat researchers’ stores.

11. Psychotherapy Rests on a Foundation of Absolute Truths, BeyondQuestioning, Examination, and Falsification

Here is a small sample of the absolute truths in the virtual foundation of the field ofpsychotherapy: There are mental illnesses, diseases, and disorders. Biological, neurolog-ical, physiological, and chemical variables are basic to psychological variables. Responseswith satisfactory consequences tend to be strengthened, and responses with unsatisfac-tory consequences tend to be weakened. The brain is a basic determinant of human behav-ior. There are psychobiological stages of human development. There are universal basicneeds, drives, and motivations. Therapists first diagnose and assess the problem or men-tal disorder and then apply the appropriate treatment. The therapist-client relationship isprerequisite to therapeutic change. Clients seek therapy for relief of problems and distress.

The catechism of absolute truths is so hallowed that it is elevated virtually beyondserious questioning and examination of where these truths came from, of what endowsthem with the mantle of absolute truths, and of just why we should worship them as basicscientific knowledge. One common answer is that great thinkers proclaimed them asabsolutely true. Another common answer is that they were bequeathed by what we simplyaccept as more fundamental sciences such as biology, neurology, physiology, and exper-imental psychology. A third common answer is that they were placed there by basicresearchers.

However, a serious problem is that these absolute truths are accepted as true more onthe basis of trusting faith than careful questioning (Feigl, 1959; Feyerabend, 1972; Mahrer,1995, 1996; Meehl, 1978). Almost without exception, none of these absolute truths hasbeen examined in a way that could find them to be false, wrong, disconfirmed, disproven,or unworthy of a place in a respected pool of absolute truths. Nor have many, if any, ofthese absolute truths been admitted to or removed from this pool on the basis of rigorousresearch scrutiny (Chalmers, 1982; O’Donohue, 1989). The conclusion may well be thatpsychotherapy rests on a foundation of supposedly absolute truths that are beyond ques-tioning, examination, or falsification. Most of what we accept as absolutely true is acceptedas true because we unquestioningly accept it as true.

Perhaps one solution is to dare to expose our hidden basic axioms, our virtuallyunquestioned basic truths, to wholesale and refreshing study, examination, and explora-tion. The first step may consist in identifying just what they are. The next step mayinvolve examining them closely in a spirit of willingness to open them up to carefulrefinement, modification, or even radical replacement. Here is a powerful challenge andopportunity for theoreticians, philosophers of science, and perhaps researchers.

Conclusion and Invitation

A case is presented that the field of psychotherapy has some embarrassing problems thatare collectively denied and that it is important for the field to admit these problems existso that steps can be taken toward their resolution. A provisional list of 11 problems is


proposed, together with suggested avenues toward solution. The invitation is to consider,revise, improve, and extend the list of embarrassing problems in a spirit of open debateand discussion to help advance the field of psychotherapy by enabling efforts towardresolution of these embarrassing problems. The dangling other end of the invitation is afriendly challenge to improve upon and to offer better solutions than those suggested atthe end of each embarrassing problem.

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Talley, P.F., Strupp, H.H., & Butler, S.F. (Eds.). (1994). Patterns of change. New York: BasicBooks.


Documents

Embarrassing problems for the field of psychotherapy