Contemporary Challenges and New Directions in Psychotherapy: An Introduction Ä

Michelle G. Newman and Louis G. Castonguay The Pennsylvania State University

As we are entering the new millennium, the field of psychotherapy is confronted with a number of unresolved issues and difficult challenges. Chief among them is a growing recognition of a large gap between the professional reality of practicing clinicians and the work of psychotherapy researchers. Researchers, for instance, have devoted a tremendous amount of effort toward developing empirically supported treatment protocols (Chambless & Hollon, 1998). The use of manualized treatments in clinical practice and training, however, has been the object of vigorous debates (see Elliot, 1998). The attitude toward the DSM classification system is another example of the current lack of convergence between clinical practice and empirical investigation. For most researchers, the use of DSM criteria is a sine qua non condition for increasing sample homogeneity and specificity (let alone any hope of funding). On the other hand, the reliance on symptoms and categorical assessment entailed by these criteria is perceived by many clinicians as a restrictive and frequently inadequate strategy to capture the complexity of clients’ problems, as well as the breadth and depth of change resulting from psychotherapy. In addition, clinicians frequently lament that current psychotherapy research is not informed by the phenomena they observe and the problems they deal with in their dayto-day practice. Not surprisingly, few practitioners find research findings to be a primary source of information to guide their clinical decisions. For many, the substantial rift between practice and research has been maintained, if not fostered, by the public policies that have guided research funding and that have made controlled clinical trials a priority. With a clear emphasis on treatment manuals (which frequently focus on techniques and pay little attention to interpersonal processes), strict (DSM-based) inclusion and exclusion criteria, symptom reduction, fixed-length treatment, and randomization, such funding policies have prioritized issues of internal validity and efficacy at the expense of issues of external, clinical validity and effectiveness. Although perceived as disconnected Preparation of this article was supported in part by National Institute of Mental Health Research Grant MH-58593. Correspondence concerning this article should be addressed to Michelle G. Newman, Ph.D., Department of Psychology, 310 Moore Building, Penn State University, University Park, PA 16802–3103; e-mail: [email protected]

JCLP/In Session: Psychotherapy in Practice, Vol. 55(11), 1321–1323 (1999) © 1999 John Wiley & Sons, Inc.

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from clinical practice, the results of such controlled clinical trials may eventually dictate reimbursement policies of HMOs and, thus, have a tremendous impact on clinical practice. To help bridge the gap between the work of researchers and the concerns of clinicians, it may be worthwhile to pay attention to a number of important questions: What are some of the directions that investigators and public policy makers should follow to increase the relevance of future studies for practice? How can we disseminate clinically relevant research in a way that would be helpful for the practicing clinicians? Would it be possible to find ways for clinicians to provide feedback or clinical input to researchers about the relevance of their research or the effectiveness of their treatment protocols in natural settings? How can we facilitate the participation of practicing clinicians in research? Each of these questions are related to the crucial issue of establishing a better dialogue and collaboration between researchers and clinicians that ultimately might prove to be necessary to better understand the complexity and improve the effectiveness of psychotherapy. In addition to the gap between research and clinical work, the field of psychotherapy is still struggling with a number of unanswered questions as it is completing its first century of modern history. What have we learned from more than 40 years of outcome research in terms of the strengths and limitations of current psychotherapy approaches? In other words, what works and what does not work (and for whom)? Is it possible to gain a consensus with regard to psychological interventions, such as a list of therapeutic guidelines to use in specific conditions or in response to particular therapeutic events? How much has basic and process research allowed us to delineate the mechanisms of change (common and unique) in treatment that have been shown to be effective? Put another way, when therapy works, how does it work? What have we learned and how much further can we benefit? Can advances in our understanding of the etiology and maintenance of psychopathology help us improve our therapeutic interventions or our ability to predict what form of treatment would be most beneficial for specific types of clients? How accurate are our current theories of psychotherapy? Which of those, if any, will stand the test of time and still be taught to future generations of therapists in the course of the next century? These questions, struggles, and challenges are the topic of the current series of articles. In addition to highlighting a number of difficult issues we are now facing, the goal of this series is to suggest ways to deal with these challenges in the near future. The series also represents a rare opportunity for clinicians and researchers to engage in an active dialogue aimed at generating recommendations to bridge the gap that exists between their work, as well as to address unresolved issues in the field of psychotherapy. The series is based on four symposia held at the 1998 Annual Meeting of the Society for Psychotherapy Research in Snowbird, Utah. The first three articles focus on specific clinical problems and address current and future directions regarding each of them from different perspectives, such as process and outcome research, basic research, theoretical models, clinical practice and training, and public policy. The first discussion, moderated by Michelle G. Newman, focuses on anxiety disorders and includes Thomas D. Borkovec, Debra A. Hope, Michael J. Kozak, Richard J. McNally, and C. Barr Taylor. The second discussion, which focuses on depression, was moderated by Louis G. Castonguay and involves the participation of Bruce A. Arnow, Sidney J. Blatt, Enrico E. Jones, Paul A. Pilkonis, and Zindel V. Segal. M. Tracie Shea moderated a third discussion on personality disorders, which includes Lorna S. Benjamin, John F. Clarkin, and Jeffrey Magnavita. The fourth article addresses some of the most important controversies associated with the Boulder-model, i.e., the bridge, or lack thereof, between psychotherapy research and clinical practice. Moderated by Marvin R. Goldfried, the discussion includes panel-

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ists representing different faces of the broad clinical-research spectrum: Thomas D. Borkovec, John F. Clarkin, Lynn Johnson, and Glenys Parry. In an attempt to delineate some of the most important dilemmas and future directions in the field of psychotherapy, Newman and Castonguay conclude this series with an article summarizing the major themes, similarities, and differences emerging from these four discussions. Select References/Recommended Readings Chambless, D.L., & Hollon, S.D. (1998). Defining empirically supported therapies. Journal of Consulting & Clinical Psychology, 66(1), 7–18. Elliot, R. (1998). Editor’s introduction: A guide to the empirically supported treatments controversy. Psychotherapy Research, 8(2), 115–125.