Clinical Impact Statement: This interview serves as a personal reflection on how the field of psychotherapy has developed in recent decades, speculates on future directions of psychotherapy, and addresses current issues regarding practice, research, and training.
Nick: You’ve been selected as the recipient of the 2018 APA/APF gold medal award for life achievement in the application of psychology, which recognizes a distinguished career and enduring contribution to the advanced application of psychology through methods, research, and/or application of psychological techniques to important practical problems. So, as you look back over your career, where do you believe the field has developed or grown most in those areas and conversely, what are the biggest challenges in these areas for the next generation of psychologists?
Marv: Let me start by referring very specifically to my experience with Division 29, which started I guess around 30 years ago. I was on the board and sat in on executive committee meetings, and one of the things that was really striking was the split between research and practice among many of the members. Even the word “clinical,” which connoted Division 12—and at the time connoted research and an anti-clinical attitude—was very evident at the time, and was a remnant of what had been going on for many years. The field of therapy started not from research but from clinical experience of Freud and his colleagues, and there was an antipathy—and still is in some circles—toward research.
Nick: For sure.
Marv: I think Division 29 has changed considerably. It’s very obvious and there is no opposition toward the need for research. There may be some tension between researchers and practitioners and I think that continues to exist. So, while in certain circles the gap between research and practice has been closed somewhat, I think it`s still a major challenge.
Nick: Right. That makes a lot of sense.
Marv: So that is a continued challenge. To a great extent one of the problems with the field is that all professionals were people before they were professionals! We know that human behavior is not always logical, so there is bias and distortion that exists, and there are personal stakes that one needs to protect. I think this personal and professional bias continues to exist and continues to inform, or perhaps at times misinform, the field.
Nick: That makes a lot of sense. That ties nicely to my next question. The closing of the research and practice gap has obviously been an important issue for you and for the field of psychotherapy. When you consider the current state of the field, what recommendations would you have, specifically for trainees and/or training programs to foster a spirit of equal emphasis at the outside of training?
Marv: Well, let me use Stony Brook University as an example. We have faculty supervising the graduate students who work in our clinic. We set that up years ago when we started the clinical program back in the late 60s, because we believed in the scientist-practitioner model, which sounds good, need a lot of work to implement practically.
Nick: For sure.
Marv: But I think at an early stage, students need to see that it’s not research versus practice, but the complementarity between the two. There are very good scientific reasons for this. One is that when good research is conducted in a science, there are usually two stages. There’s the context of discovery, where you informally look for a phenomenon. And then there’s the context of justification or verification, when you control the conditions and do research to demonstrate that yes indeed, the phenomenon exists.
Marv: And good researchers, creative researchers in the field—like Neil Miller of Dollard and Miller fame—who won awards for his research has acknowledged the importance of these two phases. For example, Miller said that he wasted a lot of time with elegant designs to study something that wasn’t there. And his point was you’ve got to have good reason to believe that the phenomenon is there. Only then should you carry out the research to demonstrate to your colleagues that the phenomenon is there. This is a roundabout way of saying that clinical practice is the context of discovery. We see things clinically and those are the things that need to be researched. Part of the clinical-research gap in psychotherapy is that researchers are not making good use of the context of discovery—clinical observation. For the context of discovery, researchers need to talk to clinicians more. And certainly, there exists work that’s being done by contemporary researchers that recognizes that. But there are still people who blindly follow the rules of research. Research is often based on what is fundable at the time, rather than what might be needed clinically. And it’s also because clinicians and researchers live in different worlds. And there are different reinforcers. The clinician gets reinforced by referrals. The researcher gets reinforced by citations.
Marv: The clinician gets reinforced by reimbursement from third-party payers and the researcher gets reinforced by grants. So even though they may have started out in the same place and in the same classroom, their worlds begin to differ. I think that’s part of the problem. And the potential solution is to have graduate students become keenly aware of this at the early outset. Research is flawed by its constrained methodology. Clinical observation is flawed by bias and misinterpretation. Which is precisely why both approaches are needed. And if both approaches, with all their flaws can come up and say there is a phenomenon here, then you can be pretty sure that there is a phenomenon there; it survived the distortion of the differential biases that are inherent in each of the methodologies.
Nick: So, when you think about graduate students at the outset of their training, are there any explicit recommendations that you would have for addressing this gap and helping more clinically oriented students to see the research side of things and vice versa?
Marv: Well, it depends on the model of the program. It used to be that this was the goal of the scientist-practitioner program. I can speak from my Stony Brook, which of course is my bias. When I do supervision, these are the same students that were in my research and theory of therapy classes. They’ve read the research, and then in clinical supervision a couple of years later, we not only talk about the consistency between the two, but also acknowledge that much of the research doesn’t address the issues that they’re grappling with clinically.
Marv: And one of the things that happens if the supervision is right on, there are recommendations that are made that come from clinical observation, rather than clinical trials. The students try it out and it works. And then you can address the issue: “Well, there’s no research on this.” And this is what researchers need to do. So there needs to be a way that when you do clinical work, to convey this information to researchers. Or if you become a researcher, that you go and get the clinical observation. I think the attitude toward clinical work and research has to be a broad one. And an open one from early on in one’s professional training—from day one.
Nick: That makes a lot of sense. The next question that I have is moving beyond the scope of training. How do you think that Division 29 psychologists can increase awareness of the research-practice gap in their research and clinical communities and take steps toward closing that? I would imagine that’s probably harder once psychologists are entrenched in whatever their views are, so how do you see that playing out?
Marv: I see that as something that needs to involve people. The people behind the professionals. There needs to be direct contact, and we have lots of evidence that prejudice can be overcome by having people come into direct contact with people that are different from themselves. I think there needs to be contact between clinicians and researchers. Operationally, I think there needs to be ongoing liaison and dialogue between members of Divisions 29 and 12, and particularly, section 3 of Division 12, Society for a Science of Clinical Psychology (SSCP). In my experience, these are the people who need to have the dialogue most, because there is this bias, and there’s much that they can learn from clinical observation.
Nick: What would you see as the most effective way…so does that mean that researchers at the university level are meeting with adjunct professors? Does that mean they’re meeting with folks of professional organizations, like SEPI or Division 29? How do you see that contact getting to occur more frequently?
Marv: It could occur at all of those venues and in a wide variety of ways. Divisions 29 and 12 have yearly meetings, and at some of these meetings, there are often presentations on issues that are important. So, presentations on diversity are presented at some of these meetings of the executive committee. There can also be presentations of talking with people from the other camp. Particularly, from the other camp from which they want to learn something. And what is important is the spirit of the venue and the spirit of what’s done. SEPI is a good example of that. When we established SEPI back in the 80s, the goal was not so much to do what was typically done at conferences, where you get people from different points of view to dialogue and where the goal is to convince the other person that they are wrong. The goal of SEPI has been to get people from different points of view to learn something from the other person. That’s a significant change.
Nick: Yes, and that makes sense.
Marv: I think the issue of the clinical-research gap has become much more serious over the years. The National Institute of Mental Health (NIMH) funding priorities of the Research Domain Criteria (RDoC) are particularly relevant here. I’ve documented this in an article appearing in the 2016 issue of Professional Psychology, pointing out that the goal of RDoC is to develop biomarkers so that drug companies can develop new medications for the treatment of psychological disorders. The profession of psychiatry depends on new and better medications for its existence, not on therapy.
Marv: The future of psychiatry depends on good meds and this is what is being funded, rather than psychotherapy research. And while there’s some hope and there’s some lobbying to get them to expand this mandate, I think that this is basically a threat from the outside of psychotherapy, and that therapy researchers and therapy practitioners need to get together to deal with this threat.
Nick: Are you optimistic that if the two branches, the practice-oriented folks and the research-oriented folks are able to come together, that the RDoC criteria will expand?
Marv: That’s a good question. It’s very hard to predict what happens. I mean, nobody could have predicted the last presidential election. We don’t know. But I’ve got to tell you this, a lot of people that use social media have been able to make dramatic changes in the world. Revolutions. Elections. Protests against assault weapons. I think a lot depends on younger professionals who see some of the difficulties in the field of psychotherapy, people such as yourself and other students of Divisions 29, 12, and other divisions. If they believe that the field needs to move in another direction, they have considerably more power than they can imagine. It’s not a prediction, but an observation.
Nick: Right. I think that, something that you really kind of see even in training programs is either an emphasis on clinical work or an emphasis on research, and in some cases an equal emphasis, but it seems like there’s very little emphasis on training psychologists to be involved at the systemic level and becoming involved in either political issues or policy issues related to the field. Do you think that that has any bearing on either where we are now or where the field is going?
Marv: I think you’ve hit on a very important point. The interesting issue is that you’re a student, but you’re also a future professional, which is a little bit different from being “just a student.” You are being trained to work within a profession and dedicate your time and energy to that profession, so you have some right in saying what that profession should look like. Graduate students do not realize how much potential power they have, because they’re beholden to the faculty for lots of things. Letters of recommendation, all kinds of other things. But believe me, faculty are very concerned about what students believe and want. When graduate students come from integrity and state their opinions, they become the leaders in the field.
Marv: Essentially, I’ve put the ball in your court and that of your fellow students.
Nick: (Laughs) I’ll do my best with that! So, to kind of pivot a little bit, you talked a little bit at the outset about the founding of SEPI, and you’re recognized as one of the driving forces behind the psychotherapy integration movement. As an advocate for psychotherapy integration, what do you regard as the most critical aspects of integrative best practices, and as a follow up to that, how would you encourage current trainees to develop competencies in psychotherapy integration?
Marv: Right. Let me start with worst practices and then move on.
Nick: Fair enough!
Marv: There are the things to be avoided. When we started the whole integration awareness, which eventually became a movement, one of the ultimate goals was to stop the proliferation of different schools of thought and to come up with principles and processes that are common. That’s been hard to achieve. As I said before, it’s because behind every professional is a person, and there are some people who are more interested in starting a school than in advancing the field. And schools of therapy are particularly problematic, even schools of integrative therapy. It adds to the proliferation.
Nick: And are there any particular aspects that you would see as best practices that you would like to see the field engage in?
Marv: I am particularly drawn to those that have a basic research foundation. One example of basic research has been that carried out on attribution or misattribution of motive. You get angry at a partner, not because of what they did, but because what you think the motive was behind it.
Marv: The attribution of motive is a mediating variable between what your partner says and your emotional reaction. If you misinterpret the motive, you may be angry. If you interpret it correctly, you may be sympathetic to your partner. This has been a replicable phenomenon experimentally. Moreover, it is a therapeutic heuristic that is extraordinarily useful when doing clinical work. When your client is angry at somebody else and you think of it in terms of a misattribution of motive, we have an evidence-based guideline on what to do clinically.
Marv: It also happens to be the premise on which behavior therapy was developed years ago as an extrapolation of basic findings. In the case of behavior therapy, it was classical and operant conditioning, and how that can be used to change people in a therapeutic situation. In many ways, I do think that that is the kind of evidence, which is far more valuable from my point of view than the evidence of randomized trials, that speaks to the clinician.
Nick: I’d like to kind of open it up for you if you have any more thoughts that we didn’t touch on related to randomized controlled trials (RCTs) and where you think the field needs to move in terms of expanding beyond the RCT.
Marv: Well, historically when the RCTs came about, which was in the ’80s, there was a shift at the NIMH. And I know this through my colleague, Barry Wolfe, who spent 22 years as a staff member at the NIMH. His monitoring of research was on anxiety disorders. He met with me before I submitted a renewal and he said there’s been a major change at the NIMH, which had become much more medically oriented. This was in the ’80s. He told me that the NIMH was no longer going to fund my research on how to reduce examination anxiety or how we can get people to become more self-assertive. He said, “We can’t fund you anymore because the NIMH wants real patients with real disorders.” The model was the medical model. What you now needed to do is diagnose a disorder by looking at the pattern of symptoms that formed a DSM syndrome. And once you’ve made the diagnosis, you then needed to develop a treatment package to treat the disorder. A problem with this was the heterogeneity within the categories, which is (finally) now recognized as being problematic. So, someone can be socially anxious because they can’t urinate in a public bathroom, and someone else with the same disorder is unable to speak to somebody interpersonally. Or someone who has difficulty speaking in front of a group. These are all diagnosed with the same disorder, so rather than treating the specific problem, you’re treating a conceptual disorder or a category.
Marv: Also, using a heterogeneous intervention, you don’t know what within the intervention may be working with what aspect of the clinical problem that is composing the disorder. This is not the way therapists work. However, this is where the field’s systemic issues become very important. Allen Frances, who was the chair of the DSM-IV, once had a dialogue once with Barry Wolfe. Barry said, “Doing the RCTs doesn’t really parallel the way clinical work is done in real practice,” to which Frances said, “Don’t worry Barry. One day clinical work will catch up, and that’s the way clinical work will be done in the future—the same way as in RCTs.”
Nick: I think that’s a really amazing point. When you see the work that’s been done with the RCT and the shape that’s had on the field, where would you like to see research really begin to focus over the next decade or so?
Marv: I think on psychological processes. It’s kind of interesting; I mean, this is the way it was in the 70s and the early ’80s. It’s interesting that within RDoC, they are now talking about mediators and moderators, and they’re talking about target behaviors, rather than DSM disorders. In the ’70s we didn’t talk about mediators and moderators, but we did talk about variables and target behaviors. Perfectionism, procrastination, unassertiveness. Characteristics that you see clinically and are a part of cognitive-affective-behavioral functioning that humans have. However, with RDoC, you can’t get biomarkers without having psychological phenomena. So even though the goal may be to get biomarkers, research also needs to focus on psychological phenomena. It’s interesting that we are going back to a pre-DSM model. The focus on mediators or moderators was once called “determining variables”—which is essentially the same. The language has changed. Essentially, what is being said is that, after three decades, we’re going back to that pre-DSM model. So, ironically enough, there may be something coming out of that.
Nick: So as a field, the pendulum is kind of moving back?
Marv: Yes, except it’s being done for a different purpose. It’s being done for finding biomarkers and eventually developing presumably more effective psychoactive drugs.
Nick: Right, okay. That makes sense.
Marv: But I do think that the basic processes are very important. It’s called “translational research.” We used to call it “extrapolation of basic research.” It’s the same empirical strategy.
Nick: It’s the same kind of principle you see across theoretical orientations. The words shift a little bit, but how frequently are we looking at different phenomena?
Marv: Exactly, yes. And of course, that creates a major problem in the field when words change. Because when you do a literature search, you do it with words. If you use the contemporary words, rather than the earlier words, you’re going to miss a lot of work that’s been done on a given topic.
Nick: Yes, definitely.
Marv: There’s been an enormous amount of clinical and research work on assertiveness and assertiveness training. But nobody searches that anymore, of course they don’t use those terms.
Nick: Right. When you think about the current state of the field of psychotherapy, what are you most excited about and/or most optimistic for, maybe in the coming decade in terms of clinical research, practice, and/or training? Do you have any thoughts on all three of those or any one in particular?
Marv: I do think that the principles or processes of change are not owned by any school of thought. Clearly, that’s where the excitement is. All schools of thought, I believe, make use of the patient’s ability to step back and observe what is going on with themselves. We call it different things. We call it de-centering, we call it metacognition, we call it mindfulness, we call it observing ego, we call it reflective functioning. There’s probably a few other labels that I’m missing. Interestingly, Freud said that the observing ego has an alliance with the analyst, and both observe the neurotic aspects of the person’s functioning. So, the ability to step back and observe yourself, this increased awareness of seeing things from a more objective point of view, is a key element in lots of forms of therapy. Now, what are the mediating and moderating variables associated with that? This is where the research should go. If you find a commonality across different schools of thought, that can be distorted by virtue of their different theoretical premises but nonetheless comes through, then that is a robust phenomenon that should be researched.
Nick: Right, right. Any other areas in which you’re, maybe even beyond basic processes that you’re excited about?
Marv: Well it’s not so much the areas, but it’s more the generation of psychologists. Psychologists who see the bigger picture. These are beginning people, starting in graduate school, who can think outside the box, who can see if the nature of the system may be interfering with what needs to be done. I think those individuals should vow to take steps to make a difference in the field.
Nick: Yes, I think that gets back to those areas where I feel like there hasn’t been enough attention. Like to recognize in training what it’s like to disrupt the field or to be able to move forward or to make a comment on policy or how funding priorities are shifting.
Marv: Yes, yes. As opposed to asking the question, “How high shall I jump?”
Nick: Right, yes. Well, you know, it feels in a lot of ways, that’s how I feel like we’re trained. To respond to the benchmarks in place and here’s how to meet those, and you see that in your own program and probably across different programs.
Marv: Well, historically in my own development, this started when I received my degree in January of 1961. This is when John F. Kennedy was inaugurated as president. He said something to the effect that “The torch is being passed to a new generation,” which I kind of liked. It resonated with me. And then he went on to add, “Any person can make a difference, and every person should try.” And that was very inspirational for me. One of the things I saw as a graduate student was this huge gap between research and practice. The clinical books, whether they’re on therapy or on the use of projective techniques, had no citations of evidence. Whereas, my readings on learning and perception did. It’s like… this is not right. This should not be. I remember that as a graduate student.
Nick: So, in closing, I’m wondering if there any other areas that you wanted to touch on or when you think of this life achievement and the application of psychology, either where you recognize where the field still has yet to move or when you think about what’s been most meaningful for you in terms of any shifts. I just want to open the floor to you aside from the questions that I generated, if there are any thoughts you have, I’d love to hear them.
Marv: How to end? Perhaps there is one more thing I’d like to underscore. The last point is: Make a difference. I think that’s because maybe this is what my role should be; more inspirational at this point. I’m not going to break through any barriers at this point in my career, so if I can inspire students and professionals to think a certain way and to think outside the box, and to try to make a difference, then that’s probably a good justification of my award.
Cite This Article
Morrison, N. (2018). Reflections from an American Psychological Association/American Psychological Foundation Gold Medal Award Recipient for Life Achievement in the Application of Psychology: An interview with Marvin Goldfried. Psychotherapy Bulletin, 53(2), 6-13.