Cover Story

Helping clients change is a cornerstone of good therapy. But how do clinicians apply this principle in their own efforts to become better therapists?

Those who have successfully transformed their practices share some common traits, notes Stony Brook University psychology professor Marvin R. Goldfried, PhD, editor of "How Therapists Change" (APA, 2001), an anthology detailing the professional journeys of 16 master clinicians. They take professional risks, even when they're unsure of the results; they harbor an open, scientific approach toward their practices; and they allow personal material to impact their work in appropriate ways.

"It's not just intellectual awareness that causes therapists to change," Goldfried comments. "It's having the opportunity to try something differently, and even though you may be somewhat skeptical about it, finding that it works and applying it."

A case in point is Washington, D.C., clinician George Stricker, PhD, of Argosy University, who recounts his experiences in the APA book. Trained psychodynamically, Stricker liked the depth and richness of the approach, but found that it wasn't a fit for some of his clients. So he learned some cognitive and behavioral approaches, and revised his notions of how change operates.

Today, "I still view clients from a psychodynamic perspective," he says, "but I'm much more willing to try things besides strict psychodynamic approaches." For instance, he prescribes homework-a cognitive-behavioral approach-and he recommends specific behavioral interventions when he feels they're needed.

Others report similar shifts, but starting from different vantage points. A cognitive-behavioral therapist may decide her approach needs the added depth of a psychodynamic perspective. A client-centered clinician may acknowledge his work would benefit from the spice of Gestalt training.

Such transmutations aren't unusual: The average practitioner changes theoretical orientations two or three times during his or her career, usually via small, integrative shifts, notes University of Scranton psychology professor John C. Norcross, PhD, who surveys psychologists' theoretical orientations and change processes. What successful change artists have in common, emphasizes Goldfried, is an openness to professional, personal and marketplace realities (see Making the most of market forces), and their willingness to improve their practices as a result.

Curious minds

For some, change is the result of ongoing intellectual and professional learning and synthesizing, a dynamic-if not always clear-cut-interplay of theory and practice.

York University psychology professor Leslie S. Greenberg, PhD, another chapter author, has undergone several such creative transformations over his 30-year career. Armed with a master's degree in engineering, the South Africa native decided to realize his dream of helping people in a more personal way by attending psychology graduate school. Over time, he learned client-centered, Gestalt and systems approaches, all of which shaped his therapy focus to become humanistic, active and relational.

Despite this broad education, a nagging gap remained: No one seemed to be addressing emotions-perhaps the key variable in therapeutic work-in a systematically theoretical way.

"It was astounding to me that emotions were exactly what psychology wasn't talking about," Greenberg says. The reasons, he posits, may be the complexity of studying these powerful and sometimes unruly forces, as well as intellectuals' fear of dealing with them.

During a sabbatical year, Greenberg tackled his concerns head-on. The result, "Emotion in Psychotherapy" (Guilford Press, 1986), by Greenberg and colleague Jeremy Safran, PhD, laid the foundations for Greenberg's development of "emotion-focused therapy," which helps people directly express, work through and transform painful emotions. Today, he uses this system with clients while incorporating elements of his earlier training.

A similar breadth of forces spurred University of Utah psychology professor Lorna Smith Benjamin, PhD, to develop her own model of psychopathology based on her view that dysfunctional internal childhood dialogues carry on into adulthood.

"I came to believe that the exotic energies and internal wars in Freudian theory didn't account for symptoms nearly as exactly as the idea of internalized interpersonal conflict," says Benjamin, another book contributor.

Today, she and her students use her interpersonal reconstructive therapy approach-the focus of numerous studies, articles and books, including "Interpersonal Reconstructive Therapy" (Guilford Press, 2003)-to help seriously mentally ill people understand and appropriately modify chronically self-destructive thoughts and actions.

"I think the old-time analysts were right in this respect: People's external symptoms are signs of deeper emotional issues," Benjamin says. In her theory, people with serious mental illnesses carry into adulthood three internalized patterns from childhood, what she calls "copy processes." In essence, they are influenced by how they perceive a childhood loved one's rules and values. They treat themselves as the loved one treated them; act as if the loved one is still present and in control; and imitate that loved one. A suicidal woman, for example, may be trying to please or appease an attachment figure who seemed not to want to have her around.

Personal revelations

Sometimes, one key incident can catalyze a new therapeutic focus. Lillian Comas-Diaz, PhD, a multicultural psychologist in Washington, D.C., and president of APA's Div. 42 (Independent Practice), says an experience working at a hospital during graduate school helped mold her into a "bilingual" therapist versed in psychological and cultural perspectives.

At the hospital, she was assigned to a ward where the patients-mostly first-generation working-class Latinos-were diagnosed with schizophrenia, largely because the mental health staff couldn't speak Spanish and wasn't familiar with Latino culture. In fact, Comas-Diaz says, the patients suffered mostly from culture-bound syndromes now described in the DSM-IV, including susto, the fear that the soul will leave the body as a result of a major distress, and "fighting attack," a stress reaction involving fighting aggressive behaviors and self-destruction.

During group sessions, the patients interpreted each others' symptoms from a spiritual perspective and recommended remedies such as herbal teas, ritual baths, and asking for forgiveness from dead ancestors, she says. While Comas-Diaz offered them ideas from a psychological standpoint, she also noticed the clients were improving using their own methods.

The experience, she says, ignited a conflict between her skeptical, scientific training and her awareness of the importance of ethnic and cultural aspects of healing-an orientation already in place because she lived some of her early years in Puerto Rico.

"Trying to integrate those things became a challenge," she says, "and it's still something of a process with clients today."

Other transformative factors

Professional support and emotional maturity also help clinicians create better practices, they say.

For example, many clinicians who contributed to "How Therapists Change" first tested the waters of change through their involvement with the Society for the Exploration of Psychotherapy Integration (or SEPI), a group started in the early 1980s by Goldfried and others who felt limited by their own models.

"Now integration is almost taken for granted," says Goldfried, "but in the beginning, there was a big stigma attached to it." The support from colleagues was therapeutic for many, who ended up expanding their practices as a result. SEPI is now an international organization of about 800 members that emphasizes "learning from, not outshining," one's colleagues, Goldfried says.

Aging itself often broadens one's professional perspective as well, comments University of Southern California psychology professor and Div. 12 (Society of Clinical Psychology) President Gerald Davison, PhD, a pioneer in bringing cognition into behavior therapy.

"Part of normal life is having problems," he says, "and you can use that part of your normal life as material to develop as a better clinician."

Stricker, like others, adds he probably wouldn't have changed if he weren't ready to.

"Part of what was required," he says, "was becoming confident enough in what I was doing to give up the crutch of adhering to a strict way of functioning."

Tori DeAngelis is a writer in Syracuse, N.Y.