For the 4th edition of Counseling and Psychotherapies in Context and Practice we added an amazing new author. I’ve introduced him on this blog before, but here’s his official bio for the new textbook:
Bryan Cochran, PhD., is a clinical psychologist, professor, and director of clinical training for the PhD program in clinical psychology at the University of Montana. His research areas of interest are LGBTIQ+ health and substance use treatment. He is the co-author of dozens of articles and book chapters on these issues, and 23 years into his academic career, has enjoyed being involved with this textbook project as a way of expanding his thinking and his knowledge of counseling theories and lenses. He doesn’t currently have a blog like John and Rita do but undoubtedly feels the pressure to do so every time he reads their musings on life and on their work. He works with clients in a clinical role using a variety of perspectives that you’ve read about in this text. While not at work, he loves hiking, swimming in Flathead Lake, hunting thrift and antique stores for mid-century treasures, and doing home renovations.
Working with Bryan has been nothing short of fabulous. . .in so many ways. Today, I’m featuring his introduction to the all-new Chapter 2, titled, Viewing Counseling and Psychotherapy Theories Through Contemporary Lenses. Here you go!
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LENSES, THEORIES, AND METHODS, OH MY!
Take a seat. We’d like to start this chapter with an eye (vision) examination. Or, if you prefer, think of this as an ear (hearing) exam. It’s both … and more. This chapter is a perception check.
Lenses clarify and distort. They provide more brightness or less brightness, an array of colors, and more clarity or more distortion. In this chapter, we’re not prescribing corrective lenses. If you’re familiar with an eye exam, think of the optometrist comparing lenses and repeatedly asking, “Which is clearer?” Your “vision” as a psychotherapist is as unique as your personal history and fingerprint.
This process—offering up different lenses for improving your perceptual acuity in counseling and psychotherapy—is far slower and more complex than an eye examination. But the analogy carries truth. As you try on and experiment with different lenses from this chapter, you may see your clients and their distress more accurately. You and your clients will benefit.
Lenses are different from theories. It may seem confusing, but our aim is to create a distinction that illuminates, rather than conflates, these concepts. Most therapy approaches in this book align with a particular theoretical perspective; behavioral psychotherapy is linked to theories of operant and classical conditioning. Psychoanalysis is deeply rooted in theories regarding the interplay of different mental structures, or psychodynamics. However, there’s no reason you can’t put on a queer theory lens when doing cognitive therapy, where you help a client to identify maladaptive thinking errors and discuss how those thoughts are likely to come about in a heteronormative society (one in which heterosexuality is the dominant paradigm for understanding relationships and family structures, and other configurations are seen as outside that norm). You can use lenses, such as critical race theory, queer theory, or intersectionality, to deepen your application of psychotherapy theories and tailor your treatment to a given client’s identities and needs.
New therapists often are frustrated by the need “to pick” a particular theoretical perspective, as if doing so means you’re entering an exclusive relationship with that choice. Like romantic partners, though, you’re unlikely to resonate with every aspect of every theoretical perspective. Unlike with a romantic partner (unless you’re setting yourself up for a series of arguments), you can analyze theoretical perspectives through various lenses to separate the parts of the theories that are most useful from those that are less useful.
So, what do we mean by a lens, in comparison to a theory? Lenses transcend disciplines—they often emerge outside of psychology but can be applied to psychological theories. Whereas a theory might tell you what to do as a therapist—what to assess, how to intervene—a lens informs how you go about doing it. Because a lens transforms how you view the world, you might adopt (or already have adopted!) a lens without being aware of it. Since one of the key principles of counseling is to understand what biases we bring into the therapeutic process, spending time talking about key lenses in a chapter new to this edition seemed like a good idea to us.
As you adapt a particular lens for viewing a counseling theory, it may be tempting to throw out the history and background of that theory because it doesn’t stand the test of time. A good example of this is the waves of critiques that have been leveled against Freudian psychoanalysis. While there are few current theorists who would say young women suffer from castration anxiety or that the Oedipal complex is a major influence on young men, the idea that some of the determinants of our behavior operate outside of our consciousness remains robust, supported by empirical research and lived experience. We believe it’s possible to hold onto both a lens and a theory at the same time. Let’s spend some time exploring some different lenses for viewing counseling and therapy so you can further develop your sense of who you might be as an emerging clinician.
Everyone agrees: Neuroscience is cool. [See above for the cover of our forthcoming text, which everyone also thinks is cool.]
Neuroscience is also complex. Most of it goes completely over my head. My guess is that I’m not alone in having neuro-limitations in my understanding of all things neuroscience.
In our theories text, we try to straddle the “Wow, neuroscience is cool” enthusiasm along with holding a “Wow, that explanation of neuroscience seems oversimplistic” attitude. Below, is my biased personal reflection (over a 45 year period) which made the cut in the latest edition of our counseling and psychotherapy theories text. Enjoy!
In 1980, I (John) began my career in mental health as a recreation therapist in a 22-bed psychiatric hospital. Many patients were actively experiencing severe depression, mania, auditory hallucinations, delusions, and aggressive behaviors.
An intimidating biological psychiatrist (Dr. M) roamed the unit. He would smile dismissively as I engaged patients in the “Newlyfriend Game” (like the old television-based Newlywed Game, only better), relaxation groups, bowling nights, and ice cream socials. Occasionally Dr. M cornered me, explaining how recreational programs had no influence on patients’ mental health. He waxed eloquent about brain chemistry. He acknowledged that the Thorazine and Haldol he prescribed had nasty side effects, but he claimed that eventually designer drugs that restored neurochemical balance and cured mental disorders would make everything else irrelevant.
The chemical imbalance theory of mental disorders dominated mental health etiology through the 1980s and 1990s. Etiological explanations focused on too much dopamine (causing schizophrenia) and not enough norepinephrine or serotonin (causing depression). No one knew what caused these so-called imbalances, but biogenetic factors were prime suspects. Although I kept silent with Dr. M, I held tight to my beliefs that social, psychological, and physical experiences could be therapeutic.
As I pursued graduate studies and accumulated post-graduate knowledge, I found evidence to support my beliefs about the two-way relationship between experiences and bio-physiological changes. One study showed that testosterone levels vary as a function of winning or losing tennis matches (Booth et al., 1989). If testosterone levels changed based on competitive tennis, what other ways might human experiences influence the brain? Another study showed that treadmill running increased serotonin availability in rats (Chaouloff, 1997). It seemed likely that acute physical exercise might also increase serotonin in human brains, possibly reducing depressive symptoms.
Then, along came two bombshells: epigenetics and neurogenesis. Epigenetics is an evolving term that refers to how behavioral experiences influence cellular activity, which, in turn, activates or deactivates genes, without altering underlying DNA (Ospelt, 2022). Environmental toxins, stress, smoking, and diet are experiences that can affect gene expression; these experiences may lead to physical changes and increased or decreased disease risk. One common implication involves how conditions of poverty predict adverse epigenetic changes—potentially increasing risk for negative physical and mental health outcomes (Assari & Zare, 2024).
Neurogenesis is the creation of new brain cells. It has been long known that during fetal development, cells are created and migrate to specific places in the brain and body where they engage in specific roles and functions. Cells that become rods and cones end up in the eyes, while other cells become bone, and still others end up in the cerebral cortex. In the 1980s and 1990s, everyone agreed that neurogenesis continued during infancy, but most neuroscientists believed that after early childhood neurogenesis stopped. In other words, as adults, we only experienced neuronal pruning (cell death).
In the late 1980s, neuroscientists began conducting research that shook long-held assumptions about neurogenesis. One research team (Jenkins et al., 1990) housed adult monkeys in cages where the monkeys had to use their middle finger to rotate a disc to get banana pellets. Even after a short time (1 week), brain autopsies showed that the monkeys had an enlarged region in their motor cortex. The conclusion: in adult monkeys, repeated physical behaviors stimulated neurogenesis in the motor cortex. This seemed like common sense. Not only do our brains shape our experiences, but our experiences shape the brain (literally).
As it turns out, neurogenesis slows with age but doesn’t stop. It continues throughout the lifespan. New learning stimulates cell birth and growth in the hippocampus (and other areas involving memory processing and storage). This “new brain research” left open the possibility that counseling and psychotherapy might stimulate neurochemical changes and cell birth in the human brain.
As brain research accelerates, implications and applications of neuroscience to counseling and psychotherapy have flourished (Satel & Lilienfeld, 2013). Practitioners have created new marketing terminology like “brain-based therapy,” “neuropsychotherapy,” “neurocounseling,” and “interpersonal neurobiology,” despite the lack of clear scientific evidence to support these terms. In some cases, the birthing of this new terminology has caused lamentation within the neuroscience, genetics, and academic communities (Bott et al., 2016; Horsthemke, 2022; Lilienfeld et al., 2015).
Appreciating Neuroscience and Epigenetic Complexities
Where does all this take us? As Dr. M would say, the brain and biogenetic predispositions are central to mood and behavior change. We now know that the reverse is also true: mood, behavior, and social interaction are central to brain development, gene expression, and change. The influences are bidirectional. More importantly, we need to acknowledge that relationships between and among brain structures, neurotransmitters, hormones, other chemicals, human behaviors, and gene expression are extremely complex and still largely unexplained. The whole brain is functioning, as well as regions, and inter- and intracellular processes, while doing all these activities both sequentially and simultaneously.
Many students in psychology, counseling, and social work have strong interests in neuroscience. We think that’s great news. Neuroscience illuminates our understanding of psychological, emotional, social, spiritual, and other processes—and neuroscience will only grow in helping us understand what’s happening in the brain. That said, when we hear students say, “I love neuroscience!” we also feel concerned about where they’re getting their neuroscience knowledge. Too often, we hear students’ ideas about specific structures (e.g., amygdala, hippocampus, prefrontal cortex) or specific neurotransmitters (e.g., serotonin, norepinephrine, dopamine). Talking about the role of brain structures and neurotransmitters runs the risk of reductionism. Just as clients are much more than diagnostic labels, their aggression is much more than an “amygdala hijack.” Neuroscience is exceedingly complex. Most of us will learn just enough neuroscience from workshops and classes to practice simplistic reductionism. To emphasize neuroscience complexity, we would like to share a summary of a recently published neuroscience article. Here’s our selection for today (there will be more tomorrow). This is from an abstract of an article titled, “Mindfulness meditation and network neuroscience: Review, synthesis, and future directions,” published in the journal, Biological Psychiatry: Cognitive Neuroscience and Neuroimaging:
In this review, we begin by defining network neuroscience and providing an overview of the common metrics that describe the topology of human structural and functional brain networks. Then, we present a detailed overview of a limited but growing body of literature that has leveraged network neuroscience metrics to demonstrate the impact of mindfulness meditation on modulating the fundamental structural and functional network properties of segregation, integration, and influence. Although preliminary, results across studies suggest that mindfulness meditation results in a shift in connector hubs, such as the anterior cingulate cortex, the thalamus, and the mid-insula. (Prakash et al., 2025, p. 350)
Before reading this excerpt, you may have thought that the neuroscience on how mindfulness meditation affects the brain was straightforward. After reading this excerpt, please take a moment and bow in respect to the complexity of neuroscience and to the large brains of neuroscience researchers. In your spare time, you may want to similarly immerse yourself in deeper readings on epigenetics (Assari & Zare, 2024; Horsthemke, 2022; Ospelt, 2022).
Today I found a creepy AI audio summary of the 3rd edition of our theories text. Maybe I should have liked it, because it was super-glowing. But the AI voice overweening on my behalf felt wrong.
In contrast, the following content is real and excerpted from our forthcoming 4th edition of Counseling and Psychotherapy Theories in Context and Practice
To continue with the creepy, the following is what was generated when I asked ChatGPT to create an image of itself.
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Theories and lenses are tools we use to make sense of our complicated world. We’re not saying that the world is more complicated in 2026 than it was 23 years ago, when the first version of this text was published, but the proliferation of information in the modern digital age means that there’s more to sift through than our brains can handle. We hope this text provides you with intellectual structure, insights, practical tools, and fun companionship on your road to understanding and engaging in counseling and psychotherapy.
While walking across the University of Montana campus the other day (which is beautiful on any day, but especially during the fall here in Montana), we noticed an annual tradition on campus had recurred—a fresh, large, orange pumpkin was placed on the top of a spire on University Hall, over 100 feet above the ground, just in time for Halloween. The impossibly steep roof of the clock tower, and the brazenness of putting a fresh gourd up there each year (for decades!) leads to speculation—let’s call them theories—about how a pumpkin could possibly make it on top of the spire.
Is it a renegade group of rock climbers who scale the building each October? Is the University somehow complicit in keeping the tradition alive while sternly warning students not to climb the building? With advancements in drone technology, has someone figured out how to hoist a heavy pumpkin and drop it on that precise point? Is it a 3-D optical phenomenon that doesn’t exist other than in socially constructed reality?
Which theory is correct? But what if it’s not one theory; maybe the pumpkin tradition has evolved over time. After decades of being on campus, our guess is, we’ll never know. The same is probably true with theories and lenses of counseling. We’ll never know—for certain—if the perspective we take is “the correct” one. The best we can do is continue learning about human behavior and the theories that explain it and do our best for our clients by using lenses and theories to help understand their unique situations and help make things better. The pumpkin problem is much easier.
We encourage you to carry theories and lenses from this textbook around with you to help you to make sense of the world—not just in terms of counseling and therapy, but in terms of understanding complexities of the world we live in. At a time where there’s a tendency to over-rely on artificial intelligence to get “the answer” to your questions, playing with different theories is good for your neural connectivity—and probably good for your clients’ well-being, because embracing and valuing different perspectives is good for all of us as we try to navigate this wildly complex world.
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We believe in several things: First, we cannot help but be affected by contemporary socio-cultural-political events. Second, regardless of socio-cultural-political movements, the counseling and psychotherapy space needs to be safe, sacred, and inclusive for everyone, and especially people with limited resources, diverse identities, and a history of distress or trauma. Third, although we talk about creating a safe space for clients to explore their lives, our offices are not instantly safe, and simply saying the words, “this is a safe space” won’t magically create trust and safety. We need work with clients to, over time, make it experientially safe.
We hope you can use the theories in this text to create and support an inclusive psychotherapy where positive and transformative work happens.
WHAT’S NEW IN THE FOURTH EDITION?
We’ve been receiving solicited and unsolicited feedback on this “Theories text” since 2003. Most of the feedback has been overwhelmingly positive. At conferences, people often approach us and say how much they love this book. They love the anecdotes, our irreverent attitudes, and our occasional efforts at humor. Yes, we believe this theories text is the funniest one on the market. Positive feedback from students and faculty has been incredibly affirming, mostly because our primary goals were to create an engaging, interesting, and practical theories text.
As a side note, we recognize there’s not much competition for funniest theories book on the market. But if there was a formal theories textbook humor competition, we would win hands down.
We’ve also received constructive feedback. Although less affirming, constructive feedback is essential to our personal and professional growth and development. We’ve tried to use constructive feedback to create an even better textbook. We invite you to provide us with whatever type of feedback you like.
So. . .what’s new in the Fourth Edition?
To add perspective to the text, we added a co-author. Bryan Cochran is a professor of psychology and LGBTIQ+ scholar. His voice and perspective are woven into every chapter, but especially our two new chapters. In chapter 2, Bryan describes several lenses that influence how we all practice counseling and psychotherapy. These lenses include: (a) Critical race theory; (b) Queer theory; (c) Intersectionality, and (d) a few other important contemporary perspectives. These lenses are not counseling or psychotherapy theories, but they can and should be used with theories and evidence-based approaches to make us more sensitive, humble, and competent in working with all clients.
In chapter 13, Bryan takes us on a deep dive into third wave behavioral treatments. These treatments include:
Mindfulness-based stress reduction (MBSR),
Dialectical behavior therapy (DBT),
Prolonged exposure (PE), and
The unified protocol (UP).
Each of these treatments incorporate mindfulness; they also have substantial empirical support. Learning about them will make you a better therapist.
To better address culture and social justice issues, we’ve done what Derald Wing Sue recommended 15 years ago. We eliminated the “multicultural chapter” and distributed cultural and diversity content throughout the other chapters, with a big emphasis in chapter 2. Our goal was to more fully integrate diversity into all theoretical approaches. We look forward to hearing from you regarding whether we accomplished that goal.
As before, every chapter includes sub-sections titled (a) cultural sensitivity, (b) gender and sexuality, and (c) spirituality. As it turns out, we still haven’t discovered the neurological basis of everything, but apparently folks are still trying. Neuroscience is featured in chapter 1 and incorporated throughout the text via the “Brain Box” feature that appears in most chapters.
WORDS TO (and from) THE WISE
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Language is liberating and activating. Although we’ve done our best to follow professional language guidelines, no doubt, sometimes you will react to our language choices, our examples, and our content. If we were in the same room as you as you had an emotional reaction, we would say something like, “Thank you for your passion.” And then we would do our best to non-defensively explore your reaction and our language, example, or content. If you engage in class discussions with classmates (or your instructor) about this text, we hope you will afford each other mutual respect and compassion for the emotions that can and will arise from studying counseling and psychotherapy.
But these posts are more than just about counseling and psychotherapy theories. They’re also about life. My first title was something like, “Things Everyone Should Know about Counseling and Psychotherapy Theories.” So, for episode one of the Theories Series, I’ve used both titles. Going forward, it will just be the Theories Series.
Each Theories Series episode will include an excerpt from our forthcoming 4th edition of our textbook, Counseling and Psychotherapy Theories in Context and Practice. As you may have heard, our theories text is, hands down, the funniest theories text on the market. As you may have also heard, the bar for producing the funniest theories text is rather low.
Here we go. The jokes are free, so they may also be worthless.
Many students ask us, “Should I get a PhD in psychology, a master’s degree in counseling, or a master’s in social work?”
This question usually brings forth a lengthy response, during which we not only explain the differences between these various degrees but also discuss additional career information pertaining to the PsyD degree, psychiatry, school counseling, school psychology, and psychiatric nursing. This sometimes leads to the confusing topic of the differences between counseling and psychotherapy. If time permits, we also share our thoughts about less-confusing topics, like the meaning of life.
The famous strategic therapist Jay Haley (1977) was once asked: “In relation to being a successful therapist, what are the differences between psychiatrists, social workers, and psychologists?” He responded: “Except for ideology, salary, status, and power, the differences are irrelevant” (p. 165). Many different professional tracks lead toward becoming a successful mental health professional—despite a few ideological, salary, status, and power differences.
In this section, we explore three challenging questions: What is psychotherapy? What is counseling? And what are the differences between the two?
[the excerpt skips some ground here]
A Working Definition of Counseling and Psychotherapy
Counseling and psychotherapy are mostly similar and often overlapping. Therefore, we use the words counseling and psychotherapy interchangeably. Sometimes we use the word therapy as a generic term representing psychosocial interventions.
To capture the natural complexity of this thing we call counseling or psychotherapy, we offer a 12-part working definition of counseling and psychotherapy. Counseling or psychotherapy is:
(a) a process that involves (b) a trained professional who abides by (c) accepted ethical guidelines and has (d) competencies for working with (e) diverse individuals who are in distress or have life problems that led them to (f) seek help (possibly at the insistence of others) or they may be (g) seeking personal growth, but either way, these parties (h) establish an explicit agreement (informed consent) to (i) work together (more or less collaboratively) toward (j) mutually acceptable goals (k) using theoretically based or evidence-based procedures that, in the broadest sense, have been shown to (l) facilitate human learning or human development or reduce disturbing symptoms.
Although this definition is long and multifaceted, it’s still probably insufficient. For example, it wouldn’t fit self-administered therapies, such as self-analysis or self-hypnosis—although we’re quite certain that if you read through this definition several times, you’re likely to experience a self-induced hypnotic trance.
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Hahaha. People come for the theories, but they stay for the jokes.
You may be wondering (I know I am), what does a glimpse and quote from the illustrious Laura Perls have to do with suicide prevention slides for North Carolina State University?
If you have thoughts on the connection, please share. I see a connection, but maybe it’s just because I wanted to post both these things. First, here’s a bit of content from Laura Perls from our Counseling and Psychotherapy Theories text.
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Although the contributions of Laura Posner Perls to Gestalt therapy practice were immense, she never receives much credit, partly due to the flamboyant extraversion of Fritz and partly because her name, somewhat mysteriously (at least to us), is not on many publications. She does, however, comment freely on Fritz’s productivity at the twenty-fifth anniversary of the New York Institute for Gestalt Therapy (an organization that she co-founded with Fritz).
Without the constant support from his friends, and from me, without the constant encouragement and collaboration, Fritz would never have written a line, nor founded anything. (L. Perls, 1990, p. 18)
REFLECTIONS
We hear resentment in the preceding quotation from Laura Perls. We feel it too, because we’d like to know more about Laura and for her to have gotten the credit she deserved. If you want more Laura, here’s a nice tribute webpage: https://gestalt.org/laura.htm?ya_src=serp300. And here’s a quotation from her (obtained from the webpage and compiled by Anne Leibig): “Real creativeness, in my experience, is inextricably linked with the awareness of mortality. The sharper this awareness, the greater the urge to bring forth something new, to participate in the infinitely continuing creativeness in nature. This is what makes out of sex, love; out of the herd, society; out of wheat and fruit, bread and wine; and out of sound, music. This is what makes life livable and incidentally makes therapy possible.”
Now, don’t you want to hear more from Laura?
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And here’s the North Carolina State University link:
We’re in the throes of editing our Theories text, meaning I’m so deep into existential, feminist, and third wave counseling and psychotherapy theories that I may have lost myself. If any of you find me somewhere on the street babbling about Judith Jordan and Frantz Fanon and Bryan Cochran, please guide me home.
This brings me to a big ask.
As part of 4th wave feminism, we’re more deeply integrating intersectionality into the practice of feminist therapy. Among other things, intersectionality is about identity. I’m interested in using a variation of Irvin Yalom’s “Who are you?” group technique to explore identity in anyone willing to respond to this post.
To participate, follow these instructions.
Clear a space for thinking, writing, and exploring your identity.
Ask yourself the question: “Who am I?” and write down the response as it flows into your brain/psyche.
Repeat this process nine more times, for a total of 10 responses, numbering each response. One rule about this: You can’t use the same response twice.
After you finish your list of 10, write a paragraph or two about how you were affected by this activity.
If you’re comfortable sharing, send me your list of 10 identities along with your reflections (email: john.sf@mso.umt.edu). If you prefer the more public route, you can post your responses here on my blog. Either way, because I’m in 24/7 theories mode, you may not hear back from me until middle November!
There’s a chance I might want to quote one or more of you in the theories text, instructor’s manual, student guide, or in this blog. If that’s the case, I will email you and request permission.
Thanks for considering this activity and request. Identity and identity development are fascinating. Whether we’re talking about multiple identities (intersectionality), emotions and behaviors (Blake), or the “microbes within us” (Yong), we all contain multitudes.
While reviewing and revising the behavior therapy chapter from our Theories textbook, I found myself revisiting my awe of Mary Cover Jones. I think too many contemporary therapists don’t know about Mary Cover Jones and don’t understand the behavioral (classical conditioning) model for understanding and treating anxiety disorders, including OCD and PTSD.
In most chapters, we include a feature called a “Brain Box.” Here’s the box from Chapter 7, Behavior Theory and Therapy.
7.1 Brain Science May be Shiny, but Exposure Therapy is Pure Gold
In honor of Joseph Wolpe, let’s start with mental imagery.
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Imagine you’ve travelled back in time to your first week of high school. You look around and see that one of your classmates is named Mary Jones.
Mary is an ordinary girl with an ordinary name. Over the years, you don’t notice her much. She seems like a nice person, a fairly good student, and someone who doesn’t get in trouble or draw attention to herself.
Four years pass. A new student joined your class during senior year. His name is Daniel Tweeter. Toward the end of the year, Daniel does a fantastic Prezi presentation about a remarkable new method for measuring reading outcomes. He includes cool video clips and boomerang Snapchat. When he bows at the end, he gets a standing ovation. Daniel is a good student and a hard worker; he partnered up with a college professor and made a big splash. Daniel deserves recognition.
However, as it turns out, over the whole four years of high school, Mary Jones was quietly working at a homeless shelter; week after week, month after month, year after year, she was teaching homeless children how to read. In fact, based on Daniel’s measure of reading outcomes, Mary had taught over 70 children to read.
Funny thing. Mary doesn’t get much attention. All everybody wants to talk about is Daniel. At graduation, he wins the outstanding graduate award. Everyone cheers.
Let’s stop the visualization and reflect on what we imagined.
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Like birds and raccoons, humans tend to like shiny things. Mary did incredible work, but hardly anyone noticed. Daniel did good work, and got a standing ovation and the top graduate award.
The “shiny-thing theory” is my best explanation for why we tend to get overly excited about brain science. It’s important, no doubt, but brain imaging isn’t therapy; it’s just a cool way to measure or validate therapy’s effects.
Beginning from at least 1924, when Mary Cover Jones was deconditioning fear out of little children, behavior therapy has shown not only great promise, but great outcomes. However, when researchers showed that exposure therapy “changes the brain,” most of the excitement and accolades were about the brain images; exposure therapy was like background noise. Obviously, the fact that exposure therapy (and other therapies) change the brain is great news. It’s great news for people who have anxiety and fear, and it’s great news for practitioners who use exposure therapy.
This is all traceable to neuroscience and human evolution. We get distracted by shiny objects and miss the point because our neural networks and perceptual processes are oriented to alert us to novel (new) environmental stimuli. This is probably because change in the form of shiny objects might signal a threat or something new and valuable. We therefore need to exercise self-discipline to focus in and not overlook that behavior therapy in general, and exposure therapy in particular, has been, is, and probably will continue to be, the most effective approach on the planet for helping people overcome anxiety and fear. In addition, you know what, it doesn’t really matter that it changes the brain (although that’s damn cool and affirming news). What matters is that it changes clients’ lives.
Exposure therapy, no matter how you package it, is highly effective for treating anxiety. This statement is true whether we’re talking about Mary Cover Jones and her evidence-based counterconditioning cookies or Francine Shapiro and eye movement desensitization reprocessing (EMDR). It’s also true whether we’re talking about virtual reality exposure, imaginal exposure, massed exposure, spaced exposure, in vivo exposure, interoceptive exposure, response prevention (in obsessive-compulsive disorder), or the type of exposure that acceptance and commitment therapists use (note that they like to say it’s “different” from traditional classical conditioning exposure, but it works, and that’s what counts).
In the end, let’s embrace and love and cheer brain imaging and neuroscience, but not forget the bottom line. The bottom line is that exposure therapy works! Exposure therapy is the genuine article. Exposure therapy is pure gold.
Mary Cover Jones is the graduate of the century; she was amazing. Because of her, exposure therapy has been pure gold for 93+ years, and now we’ve got cool pictures of the brain to prove it.
Mary Cover Jones passed away in 1987. Just minutes before her death, she said to her sister: “I am still learning about what is important in life” (as cited in Reiss, 1990).
On July 24, in Helena, I attended a fun and fascinating meeting sponsored by the Carter Center. I spent the day with a group of incredibly smart people dedicated to improving mental health in Montana.
The focus was twofold. How do we promote and establish mental health parity in Montana and how do with improve behavioral health in schools? Two worthy causes. The discussions were enlightening.
We haven’t solved these problems (yet!). In the meantime, we’re cogitating on the issues we discussed, with plans to coalesce around practical strategies for making progress.
During our daylong discussions, the term evidence-based treatments bounced around. I shared with the group that as an academic psychologist/counselor, I could go deep into a rabbit-hole on terminology pertaining to treatment efficacy. Much to everyone’s relief, I exhibited a sort of superhuman inhibition and avoided taking the discussion down a hole lined with history and trivia. But now, much to everyone’s delight (I’m projecting here), I’m sharing part of my trip down that rabbit hole. If exploring the use of terms like, evidence-based, best practice, and empirically supported treatment is your jam, read on!
The following content is excerpted from our forthcoming text, Counseling and Psychotherapy Theories in Context and Practice (4th edition). Our new co-author is Bryan Cochran. I’m reading one of his chapters right now . . . which is so good that you all should read it . . . eventually. This text is most often used with first-year students in graduate programs in counseling, psychology, and social work. Consequently, this is only a modestly deep rabbit hole.
Enjoy the trip.
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What Constitutes Evidence? Efficacy, Effectiveness, and Other Research Models
We like to think that when clients or patients walk into a mental health clinic or private practice, they will be offered an intervention that has research support. This statement, as bland as it may seem, would generate substantial controversy among academics, scientists, and people on the street. One person’s evidence may or may not meet another person’s standards. For example, several popular contemporary therapy approaches have minimal research support (e.g., polyvagal theory and therapy, somatic experiencing therapy).
Subjectivity is a palpable problem in scientific research. Humans are inherently subjective; humans design the studies, construct and administer assessment instruments, and conduct the statistical analyses. Consequently, measuring treatment outcomes always includes error and subjectivity. Despite this, we support and respect the scientific method and appreciate efforts to measure (as objectively as possible) psychotherapy outcomes.
There are two primary approaches to outcomes research: (1) efficacy research and (2) effectiveness research. These terms flow from the well-known experimental design concepts of internal and external validity (Campbell et al., 1963). Efficacy research employs experimental designs that emphasize internal validity, allowing researchers to comment on causal mechanisms; effectiveness research uses experimental designs that emphasize external validity, allowing researchers to comment on generalizability of their findings.
Efficacy Research
Efficacy research involves tightly controlled experimental trials with high internal validity. Within medicine, psychology, counseling, and social work, randomized controlled trials (RCTs) are the gold standard for determining treatment efficacy. RCTs statistically compare outcomes between randomly assigned treatment and control groups. In medicine and psychiatry, the control group is usually administered an inert placebo (i.e., placebo pill). In the end, treatment is considered efficacious if the active medication relieves symptoms, on average, at a rate significantly higher than placebo. In psychotherapy research, treatment groups are compared with a waiting list, attention-placebo control group, or alternative treatment group.
To maximize researcher control over independent variables, RCTs require that participants meet specific inclusion and exclusion criteria prior to random assignment to a treatment or comparison group. This allows researchers to determine with greater certainty whether the treatment itself directly caused treatment outcomes.
In 1986, Gerald Klerman, then head of the National Institute of Mental Health, gave a keynote address to the Society for Psychotherapy Research. During his speech, he emphasized that psychotherapy should be evaluated through RCTs. He claimed:
We must come to view psychotherapy as we do aspirin. That is, each form of psychotherapy must have known ingredients, we must know what these ingredients are, they must be trainable and replicable across therapists, and they must be administered in a uniform and consistent way within a given study. (Quoted in Beutler, 2009, p. 308)
Klerman’s speech advocated for medicalizing psychotherapy. Klerman’s motivation for medicalizing psychotherapy partly reflected his awareness of heated competition for health care dollars. This is an important contextual factor. Events that ensued were an effort to place psychological interventions on par with medical interventions.
The strategy of using science to compete for health care dollars eventually coalesced into a movement within professional psychology. In 1993, Division 12 (the Society of Clinical Psychology) of the American Psychological Association (APA) formed a “Task Force on Promotion and Dissemination of Psychological Procedures.” This task force published an initial set of empirically validated treatments. To be considered empirically validated, treatments were required to be (a) manualized and (b) shown to be superior to a placebo or other treatment, or equivalent to an already established treatment in at least two “good” group design studies or in a series of single case design experiments conducted by different investigators (Chambless et al., 1998).
Division 12’s empirically validated treatments were instantly controversial. Critics protested that the process favored behavioral and cognitive behavioral treatments. Others complained that manualized treatment protocols destroyed authentic psychotherapy (Silverman, 1996). In response, Division 12 held to their procedures for identifying efficacious treatments but changed the name from empirically validated treatments to empirically supported treatments (ESTs).
Advocates of ESTs don’t view common factors in psychotherapy as “important” (Baker & McFall, 2014, p. 483). They view psychological interventions as medical procedures implemented by trained professionals. However, other researchers and practitioners complain that efficacy research outcomes do not translate well (aka generalize) to real-world clinical settings (Hoertel et al., 2021; Philips & Falkenström, 2021).
Effectiveness Research
Sternberg, Roediger, and Halpern (2007) described effectiveness studies:
An effectiveness study is one that considers the outcome of psychological treatment, as it is delivered in real-world settings. Effectiveness studies can be methodologically rigorous …, but they do not include random assignment to treatment conditions or placebo control groups. (p. 208)
Effectiveness research focuses on collecting data with external validity. This usually involves “real-world” settings. Effectiveness research can be scientifically rigorous but doesn’t involve random assignment to treatment and control conditions. Inclusion and exclusion criteria for clients to participate are less rigid and more like actual clinical practice, where clients come to therapy with a mix of different symptoms or diagnoses. Effectiveness research is sometimes referred to as “real world designs” or “pragmatic RCTs” (Remskar et al., 2024). Effectiveness research evaluates counseling and psychotherapy as practiced in the real world.
Other Research Models
Other research models also inform researchers and practitioners about therapy process and outcome. These models include survey research, single-case designs, and qualitative studies. However, based on current mental health care reimbursement practices and future trends, providers are increasingly expected to provide services consistent with findings from efficacy and effectiveness research (Cuijpers et al., 2023).
In Pursuit of Research-Supported Psychological Treatments
Procedure-oriented researchers and practitioners believe the active mechanism producing positive psychotherapy outcomes is therapy technique. Common factors proponents support the dodo bird declaration. To make matters more complex, prestigious researchers who don’t have allegiance to one side or the other typically conclude that we don’t have enough evidence to answer these difficult questions about what ingredients create change in psychotherapy (Cuijpers et al., 2019). Here’s what we know: Therapy usually works for most people. Here’s what we don’t know: What, exactly, produces positive changes.
For now, the question shouldn’t be, “Techniques or common factors?” Instead, we should be asking “How do techniques and common factors operate together to produce positive therapy outcomes?” We should also be asking, “Which approaches and techniques work most efficiently for which problems and populations?” To be broadly consistent with the research, we should combine principles and techniques from common factors and EST perspectives. We suspect that the best EST providers also use common factors, and the best common factors clinicians sometimes use empirically supported techniques.
Naming and Claiming What Works
When it comes to naming and claiming what works in psychotherapy, we have a naming problem. Every day, more research information about psychotherapy efficacy and effectiveness rolls in. As a budding clinician, you should track as much of this new research information as is reasonable. To help you navigate the language of researchers and practitioners use to describe “What works,” here’s a short roadmap to the naming and claiming of what works in psychotherapy.
When Klerman (1986) stated, “We must come to view psychotherapy as we do aspirin” his analogy was ironic. Aspirin’s mechanisms and range of effects have been and continue to be complex and sometimes mysterious (Sommers-Flanagan, 2015). Such is also the case with counseling and psychotherapy.
Language matters, and researchers and practitioners have created many ways to describe therapy effectiveness.
D12 briefly used the phrase empirically validated psychotherapy. Given that psychotherapy outcomes vary, the word validated is generally avoided.
In the face of criticism, D12 blinked once, renaming their procedures as empirically supported psychotherapy. ESTs are manualized and designed to treat specific mental disorders or specific client problems. If it’s not manualized and doesn’t target a disorder/problem, it’s not an EST.
ESTs have proliferated. As of this moment (August 2025), 89 ESTs for 30 different psychological disorders and behavior problems are listed on the Division 12 website (https://div12.org/psychological-treatments/). You can search the website to find the research status of various treatments.
To become proficient in providing an EST requires professional training. Certification may be necessary. It’s impossible to obtain training to implement all the ESTs available.
In 2006, an APA Presidential Task Force (2006) loosened D12’s definition, shifting to a more flexible term, Evidence-Based Practice (EBP), and defining it as ‘‘the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences’’ (p. 273).
In 2007, the Journal of Counseling and Development, the American Counseling Association’s flagship journal, inaugurated a new journal section, “Best Practices.” As we’ve written elsewhere, best practice has grown subjective and generic and is “often used so inconsistently that it is nearly meaningless” (Sommers-Flanagan, 2015, p. 98).
In 2011, D12 relaunched their website, relabeling ESTs as research-supported psychological treatments (n.b., most researchers and practitioners continue to refer to ESTs instead of research-supported psychological treatments).
As an alternative source of research updates, you can also track the prolific work of Pim Cuijpers and his research team for regular meta-analyses on psychological treatments (Cuijpers et al., 2023; Harrer et al., 2025).
Other naming variations, all designed to convey the message that specific treatments have research support, include evidence-based treatment, evidence-supported treatment, and other phrasings that, in contrast to ESTs and APA’s evidence-based practice definition, have no formal definition.
Manuals, Fidelity, and Creativity
Manualized treatments require therapist fidelity. In psychotherapy, fidelity means exactness or faithfulness to the published procedure—meaning you follow the manual. However, in the real world, when it comes to treatment fidelity, therapist practice varies. Some therapists follow manuals to the letter. Others use the manual as an outline. Still others read the manual, put it aside, and infuse their therapeutic creativity.
A seasoned therapist (Bernard) we know recently provided a short, informal description of his application of exposure therapy to adult and child clients diagnosed with obsessive-compulsive disorder. Bernard described interactions where his adult clients sobbed with relief upon getting a diagnosis. Most manuals don’t specify how to respond to clients sobbing, so he provided empathy, support, and encouragement. Bernard described a therapy scenario where the client’s final exposure trial involved the client standing behind Bernard and holding a sharp kitchen knife at Bernard’s neck. This level of risk-taking and intimacy also isn’t in the manual—but Bernard’s client benefited from Bernard trusting him and his impulse control.
During his presentation, Bernard’s colleagues chimed in, noting that Bernard was known for eliciting boisterous laughter from anxiety-plagued children and teenagers. There’s no manual available on using humor with clients, especially youth with overwhelming obsessional anxiety. Bernard used humor anyway. Although Bernard had read the manuals, his exposure treatments were laced with empathy, creativity, real-world relevance, and humor. Much to his clients’ benefit, Bernard’s approach was far outside the manualized box (B. Balleweg, personal communication, July 14, 2025).
As Norcross and Lambert (2018) wrote: “Treatment methods are relational acts” (p. 5). The reverse is equally applicable, “Relational acts are treatment methods.” As you move into your therapeutic future, we hope you will take the more challenging path, learning how to apply BOTH the techniques AND the common factors. You might think of this—like Bernard—as practicing the science and art of psychotherapy.
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Note: This is a draft excerpt from Chapter 1 of our 4th edition, coming out in 2026. As a draft, your input is especially helpful. Please share as to whether the rabbit hole was too deep, not deep enough, just right, and anything else you’re inspired to share.
At long last, we’ve begun work on revising our Counseling and Psychotherapy Theories text for its 4th edition. Over the past several weeks, I’ve been putting in an hour or two a day, chipping away on chapter revisions, reaching out to reviewers, and planning with our new and very exciting co-author, Dr. Bryan Cochran, a highly esteemed psychology professor at the University of Montana. If you’re reading this, I want you to know of Bryan’s awesomeness (and if you’re Bryan, I want you to feel the pressure of this public announcement of your awesomeness) [hahahaha!]
You all probably know that our Theories textbook is far and away the Theories textbook with the most hilarity. No doubt, this is a rather low bar, given that I can’t find any funny stories in any other theories texts. We view theories hilarity to be extremely important in a theories text, because reading many theories texts can parallel the proverbial experience of watching paint dry.
Bryan’s addition to the writing team will give us something we need—an expert in the LGBTQ+ domain, and someone with a talent for telling stories that are simultaneously engaging, informative, and fun to read. Right now, he’s busy writing a “Lenses” chapter (to be Chapter 2) to orient readers to important theory-related lenses like (a) Queer theory, (b) Critical Race theory, (c) Intersectionality, and more. I, for one, can hardly wait for his Queer theory quips.
News Flash: In the past, I’ve put out broad calls for chapter reviewers. This time, I’m being selective and directly asking prominent theories experts to review chapters and offer guidance. Some examples: For the Adlerian chapter we’ve got Marina Bluvshtein (woohoo!) and Jon Sperry (wow!). For the Psychoanalytic chapter, we got Nancy McWilliams (amazing!) and Pratyusha Tammala-Narra (fantastic!).
If you happen to be a specific theories subject matter expert, you should email me at john.sf@mso.umt.edu to get in on the fun. Or if you have a prominent theories friend/colleague to recommend, have them email me.
As one last theories teaser, below I’m pasting a few excerpts from Nancy McWilliams’s 2021 article titled, “Diagnosis and Its Discontents: Reflections on Our Current Dilemma.” I love this article as it gives a glimpse into problems with contemporary diagnoses and how psychodynamic therapists use individualized assessment in ways to honor the real-life complexities clients bring into psychotherapy. The excerpts below are from her article, which is linked at the end of this post.
On Labeling
The idea that one is anxious (or depressed or obsessive) about something that has meaning is being lost. Fitting an individual into a category tends to foreclose exploration of what is unique to a patient; it especially prevents insights into unexpected aspects of a person’s psychology or exploration of areas that are felt as shameful – the very areas that are of particular value in planning and carrying out psychotherapy.
On the vexing ways in which patients think about themselves and their diagnoses
It used to be that a socially avoidant woman would come for therapy saying something like, “I’m a painfully shy person, and I need help learning how to deal better with people in social situations.” Now a person with that concern is likely to tell me that she “has” social phobia – as if an alien affliction has invaded her otherwise problem-free subjective life. People talk about themselves in acronyms oddly dissociated from their lived experience: “my OCD,” “my eating disorder,” “my bipolar.” There is an odd estrangement from one’s sense of an agentic self, including one’s own behavior, body, emotional and spiritual life, and felt suffering, and consequently one’s possibilities for solving a problem. There is a passive quality in many individuals currently seeking therapy, as if they feel that the prototype for making an internal psychological change is to describe their symptoms to an expert and wait to be told what medicine to take, what exercises to do, or what self-help manual to read.
On “chemical imbalances”
. . . viewing psychological suffering as a set of disorders that can be fixed or improved chemically can easily invite the obverse assumption that those painful experiences are ultimately caused by random or genetically based chemical differences among individuals. This is a false conclusion, of course, something like saying that because marijuana improves appetite, the cause of low appetite is lack of marijuana. But it is nevertheless a frequent leap of illogic – in the thinking of nonprofessionals and of some professionals as well – to ascribe much severe psychological suffering to a “chemical imbalance.” Such a construction tempts us to ignore all the painful other sources of psychological suffering, such as poverty, neglect, trauma, and the myriad ways in which human beings can injure each other psychologically.
On not overgeneralizing research findings/recommendations to unique patients
. . . consider patients at the extreme end of the obsessive-compulsive continuum, whose obsessions border on delusional beliefs, who suffer profound annihilation anxiety, who wholeheartedly believe they will die if they fail to carry out their rituals, and who regard the therapist with suspicion for not sharing their conviction – in other words, the subgroup of obsessive patients that Kernberg (1984) would consider as psychologically organized at the low borderline or psychotic level. My experience suggests that with this group exposure therapy not only fails, it demoralizes the patients, makes them feel like failures personally, and kills any hope they may have that psychotherapy can help. It also demoralizes therapists, who have been told again and again that exposure therapy is the treatment of choice for OCD. If they believe their teachers, such clinicians can easily conclude they are simply not good enough therapists.
If I’ve piqued your interest in “Diagnosis and its discontents” by Nancy McWilliams, here’s a pdf of the article.
John Sommers-Flanagan 