Beyond Theoretical Orientations: The Emergence of a Unified Scientific Framework in Professional Psychology
Timothy P. Melchert Marquette University
Psychology has been remarkably successful as both a basic and applied science despite serious and persistent conflict between its many theoretical camps and schools of thought. By far the most influential approaches to conceptualizing clinical practice in psychology have been the traditional theoretical orientations, even though they are widely viewed as inadequate and incomplete. This article reviews the underlying reasons for these conflicts and then discusses the emergence of a unified scientific framework that moves the profession beyond these problems. Outmoded conceptual frameworks are not appropriate for a science-based profession, and professional psychology needs to consider making a systematic transition to a comprehensive scientific approach to understanding human development, functioning, and behavior change.
Keywords: unified theory, theoretical orientations, biopsychosocial, professional psychology, psycho- logical science
Psychology has been remarkably successful as both a basic and applied science since its founding in the late 19th century. The field has had a major influence on important areas within the social sciences, education, health care, public policy, organizations and businesses, and even on culture in general. It has helped transform society’s understanding of mental health and psychological func- tioning, and psychosocial treatments have provided relief to count- less individuals suffering from psychological dysfunction and dis- tress. The professional practice of psychology has also grown remarkably. Psychologists played a small role in American health care before 1945 when the first licensure law for psychologists was enacted, and just 60 years later the number of licensed psycholo- gists grew to over 85,000 (Duffy et al., 2006).
Despite its remarkable growth and many achievements, the field has also found it challenging to develop consensus explanations of personality, psychopathology, and behavior change that provide a solid scientific foundation for the clinical practice of psychology. Scientifically verified explanations have emerged regarding many psychological phenomena, but other aspects of the tremendous complexity of human psychology have been difficult to unravel and are currently understood only in outline form. This is partic- ularly true for more complicated higher level processes that are
often the focus of psychological treatment. Many basic processes of sensation, perception, cognition, affect, learning, and develop- ment are understood in detail, but explanations are much less complete for many complex processes such as the nature and development of personality and intelligence, the nature and causes of psychopathology, and the mechanisms that account for behavior change and treatment effectiveness.
Within professional psychology (PP), by far the most influential approaches to understanding personality, psychopathology, and psychotherapy have been the traditional theoretical orientations. Standard textbooks that cover this material often take a chrono- logical approach to reviewing these orientations, starting with Freudian theory and progressing through psychodynamic, behav- ioral, humanistic, cognitive, systemic, multicultural, and integra- tive approaches. The more than 400 theoretical orientations that have now been developed vary widely in focus and scope (Corsini & Wedding, 2008). Some theories focus primarily on the devel- opment of personality and psychopathology with little emphasis on the process of psychotherapy (e.g., existentialism, multicultural approaches), while others focus primarily on therapy processes and methods (e.g., interpersonal therapy, eclectic approaches). The earliest of these theories, Freudian psychoanalysis, was the most comprehensive and thorough attempt to explain all these factors, though it also ended up being the most controversial.
These theoretical orientations continue to play very important roles in PP education and practice. For example, while it is obviously not possible to learn a large number of them in detail, learning one or more of them is generally considered required training in the field. The Application for Psychology Internship, used by nearly all psychology internship programs in the Associ- ation of Psychology Postdoctoral and Internship Centers (APPIC), requires that applicants complete the following essay question: “Please describe your theoretical orientation and how this influ- ences your approach to case conceptualization and intervention” (APPIC, 2009, p. 22). The conclusions of the American Psycho-
This article was published Online First May 7, 2012. TIMOTHY P. MELCHERT received his PhD in counseling psychology from
the University of Wisconsin-Madison. He is the Assistant Vice Provost for Graduate Programs and an associate professor in the Department of Coun- selor Education and Counseling Psychology at Marquette University. His research interests include the conceptual, theoretical, and scientific foun- dations of psychological practice and family of origin influences on de- velopment and functioning.
CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to Timothy P. Melchert, Department of Counselor Education and Counseling Psychology, 168F Schroeder Complex, Marquette University, Milwaukee, WI 53201. E-mail: [email protected]
Professional Psychology: Research and Practice © 2012 American Psychological Association 2013, Vol. 44, No. 1, 11–19 0735-7028/13/$12.00 DOI: 10.1037/a0028311
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logical Association (APA) Assessment of Competency Bench- marks Work Group (2007) also support this approach. They noted that the “ability to formulate and conceptualize cases and plan interventions utilizing at least one consistent theoretical orienta- tion” (p. 43) is an “essential component” for demonstrating clinical intervention skill. The Guidelines and Principles of the APA Commission on Accreditation (2009) are also consistent with this approach by noting that “The accreditation guidelines and princi- ples are specifically intended to allow a program broad latitude in defining its philosophy or model of training and to determine its training principles, goals, objectives, desired outcomes (i.e., its “mission”) and the methods to be consistent with these” (p. 4).
Given the central role that the traditional theoretical orientations have played in PP education and practice, it is remarkable how controversial they have been across the entire history of the field. The criticisms and weakness of these various orientations are very well known—standard undergraduate and graduate textbooks rou- tinely discuss them as part of the presentation of the theories. Even the most influential current single approach, cognitive– behavioral therapy, is widely considered inadequate as an explanation for psychotherapy change (e.g., Kazdin, 2007). (See the sections that follow for more discussion of these issues.)
The traditional theoretical orientations in PP are perhaps uni- versally considered to provide incomplete explanations of person- ality, psychopathology, and behavior change, but they continue to play central roles in the field nonetheless. Indeed, it would be difficult for many students, faculty, and practicing psychologists to imagine case conceptualizations that are not based on these orien- tations. The appropriateness of this practice from a scientific perspective, however, is clearly questionable. Is it appropriate for clinicians to select one or more of the traditional theoretical orientations to guide their approach to clinical practice if those orientations are widely viewed as incomplete and inadequate? Further, given that this practice is incorporated into major organi- zational structures within the profession, to what extent does this raise questions about the strength of the scientific foundations of the profession? This article reviews the origins and nature of these problems before going on to advocate that it is time for the field to transition to a unified science-based approach to professional practice.
To clarify the significance of these issues, this article first briefly reviews problems associated with the traditional ap- proaches to conceptualizing professional practice in psychology and then examines the most important reasons behind the confus- ing conceptual foundations of the field. The article then discusses the characteristics of a comprehensive science-based solution to these problems. Relying on outmoded theoretical frameworks for education, practice, and research is not appropriate for a science- based profession, and it is critical that PP continually re-examines these issues and updates the scientific foundations on which it is based.
Theoretical Conflict and Confusion in PP
One of the more remarkable characteristics of psychology as a scientific discipline has been the proliferation of theoretical ap- proaches to understanding the nature of psychological phenomena. Right from the start, there was major controversy regarding the most appropriate approaches to understanding psychology. Wil-
helm Wundt, who established the first psychology laboratory in 1879, argued that higher cognitive processes should not even be investigated because they were simply too complex to understand using available experimental methods. His students were only allowed to study elemental experiences such as basic sensations, associations, and feelings. By the turn of the century, Sigmund Freud was advocating for a radically different approach to under- standing human psychology that revolved around the role of the unconscious. In 1913, John Watson presented another radically different perspective, urging his colleagues to abandon their inter- est in consciousness and instead focus on behavior. Remarkably varied approaches to understanding human psychology continued to proliferate over the decades. Thomas Kuhn (1962) noted that such theoretical proliferation and competition also characterized the natural sciences when they were young and concluded that psychology was in a similar “immature” and preparadigmatic stage as the physical sciences were in the 17th century.
The proliferation of theoretical approaches in PP has continued up to the present. New eclectic and integrative approaches con- tinue to be developed (see Norcross, 2005), as well as entirely new approaches such as positive psychotherapy (Seligman, Rashid, & Parks, 2006), attachment therapy (Wallin, 2007), personality- guided relational psychotherapy (Magnavita, 2005), and coherence therapy (Ecker & Hulley, 2006). In addition, no individual ap- proach has become dominant. Surveys normally find that the largest number of adherents to any one orientation, even an eclec- tic or integrative approach, still remains a minority, usually less than one third of the sample (Prochaska & Norcross, 2010). The intensity of contention and conflict between the theoretical camps appears to have diminished in recent years (Goodheart & Carter, 2008; Magnavita, 2008; Norcross, 2005), but disagreements be- tween advocates of the differing theoretical orientations remain strong nonetheless.
In addition to conflicts between theoretical camps, there have been several other controversies and schisms that reflect confusion in the conceptual foundations of the field. In 1976, the National Council for Schools of Professional Psychology broke off from the APA because of fundamental differences regarding the appropriate training model for PP education. In 1988, a large number of psychological scientists became disillusioned with the practice emphasis of the APA and broke off to form the APA. The empir- ically supported treatment movement in PP quickly became con- troversial after the APA Division 12 Task Force on Promotion and Dissemination of Psychological Procedures applied the concept in 1995. Controversies surrounding recovered memories of child sexual abuse became so intense in the 1990s that they became known as the “memory wars” (Loftus & Davis, 2006; p. 470), one of the most conflictual periods ever in the history of psychology. Concern has also grown recently regarding discredited or poten- tially harmful therapies. Norcross, Koocher, and Garofalo (2006) conducted a survey listing dozens of treatments and asked experts about the degree to which they believed each of them had been discredited. They found 25 treatments that were rated on average as somewhere between “probably discredited” and “certainly dis- credited” (e.g., sexual reorientation therapy, rebirthing therapies, Thought Field Therapy, reparenting therapy).
Controversies and conflicts between the theoretical camps and schools of thought in psychology have been so pervasive and persistent over the decades that many psychologists seem to accept
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them as a normal, almost natural characteristic of the field. Many leaders in psychology, however, have been concerned that the field has become so conflictual and fractured that it might not be able to continue as a scholarly discipline (e.g., Gardner, 2005; Kendler, 2002; Rychlak, 2005; Staats, 2005; Sternberg, 2005). Driver-Linn (2003) noted that “Perceptions of psychology as beleaguered by fractionation and uncertainty are almost ubiquitous” (p. 270).
Reasons Underlying the Theoretical and Conceptual Confusion in PP
There is a great deal of consensus regarding the underlying reasons for the conflicts and contention within PP. These reasons are important for identifying solutions to the conflicts and so they are briefly reviewed next. There are four issues in particular that are important for understanding why theoretical development in the discipline has been especially complicated.
Philosophical Underpinnings of Many Theoretical Orientations
The theoretical and philosophical underpinnings of the histori- cally important theoretical orientations in PP are generally well- known. While the details involved are highly complicated, the basic issues can be easily summarized. Many of these orientations are based on foundational assumptions or first principles that take widely varying perspectives on human nature (e.g., biologically based drives in Freudian theory, the blank slate of nearly complete malleability in behaviorism, an optimistic self-actualizing ten- dency in humanistic theories, a postmodern constructivism in solution-focused therapy). These philosophical starting points of- ten conflict in fundamental ways that lead to irreconcilable differ- ences in the understanding of human psychology and behavior change (Messer & Winokur, 1980; Wood & Joseph, 2007). Ad- herence to these orientations consequently often involves accep- tance of their underlying philosophical assumptions or worldview as opposed to being convinced by the weight of the scientific evidence examining their validity. As a result, disagreements be- tween adherents of the different theories sometimes resemble philosophical or political disputes more than scientific ones.
Nonfalsifiability of Psychological Theories
From a scientific standpoint, many of the traditional theoretical orientations in psychology suffer from a second critical weakness. The purported mechanisms involved in the development of per- sonality and psychopathology or in behavior change obviously differ greatly across the theories (e.g., developmental fixations, one’s learning history, imposed conditions of worth, depressogenic cognitions, a constructed phenomenological worldview). Nonethe- less, many of these theories have been used to explain virtually all outcomes that occur in individual cases, and it is consequently difficult to disprove that a particular theory could account for any particular outcome (Popper, 1963). Instead of evaluating these issues on the basis of logical scientific analysis, students learning the profession are often advised to choose a theoretical orientation based on the fit between the orientations and their personality and worldview (e.g., Corsini & Wedding, 2008; Truscott, 2010).
The individual credited with first explaining the nature of this problem is the philosopher Karl Popper (1902 – 1994). As a young student in Vienna in 1919, he heard both Freud and Einstein present their work and was very impressed with both their theories. He also noticed a fundamental difference between them, however (Popper, 1963). Freud presented his theory in terms that made it amenable to confirmation, while Einstein’s theory had testable implications which, if false, would prove the theory wrong. Popper noted that many theories such as Freudianism, Adlerianism, or Marxism were only amenable to confirmation and could not be refuted. He therefore judged them to be poor theories. Popper argued that scientific theories must be refutable and, further, that genuine tests of theories are attempts to refute them.
Complexity of Human Psychology
The complicated evolution of theory in psychology also cannot be understood without appreciating the tremendous complexity of the subject matter involved. The extraordinary intricacy, complex- ity, and range of psychological phenomena make psychology an endlessly fascinating field of study, but also highly challenging. The human brain is almost unfathomably complex. In just a three-pound organ, roughly 100 billion neurons each with an average of 1,000 synaptic connections carry our own personal history, our family’s history, and even the evolutionary history of our species, while also constantly interacting with, being shaped by, and even creating one’s environment, at co-occurring subcon- scious and conscious levels. Indeed, the human mind appears to be the most complex phenomenon humans have ever attempted to understand. The biologist Richard Dawkins noted that “. . . we animals are the most complicated and perfectly designed pieces of machinery in the known universe” (1976, p. xxii), while E. O. Wilson stated that “. . .the most complex systems known to exist in the universe are biological, and by far the most complex of all biological phenomena is the human mind” (1998, p. 81).
Some of the main critiques of the traditional theoretical orien- tations have focused on their failure to fully incorporate biological and sociocultural influences on development and functioning. From a scientific perspective, there is no question that all levels of natural organization are important to understanding human psy- chology. No explanation of human development and functioning is complete that does not emphasize the interactions between biolog- ical (e.g., genetics, neurophysiology, physical health, and disease), psychological (e.g., cognition, emotion, behavior), and sociocul- tural influences on human psychology (e.g., family, community, culture, religion, education, socioeconomic factors). The tradi- tional theoretical orientations in psychology, however, were gen- erally not designed to be comprehensive in this manner.
Power and Precision of Available Scientific Tools
Another critical perspective for understanding the evolution of scientific disciplines involves the power and precision of the scientific tools available for examining phenomena. The role these tools play in the development of the physical sciences is very well-known, but their importance is often underappreciated in the social sciences. Scientific progress is directly dependent on these tools, and some of the most important ones have been conceptual rather than technological. For example, mathematics in Europe
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was written out in words prior to the 13th century when algebra and symbolic mathematics were invented. Vastly more complex calculations could then be performed and science and commerce were transformed as a result. Four centuries later, Newton’s and Leibnitz’s invention of calculus proved to be so useful that science was again transformed. The use of calculus quickly led to major advances in understanding the nature of gravity, heat, light, sound, fluid dynamics, electricity, and magnetism. The more recent de- velopment of statistics and advanced mathematical modeling again transformed the kinds of phenomena that could be investigated and explained.
Scientific progress is also heavily dependent on the develop- ment of technological tools. For example, Copernicus hypothe- sized that the earth revolved around the sun in 1543, but his hypothesis could not be confirmed until Galileo built his first telescope in 1609. Each further advance in telescope technology over the centuries has tended to result in important advances in understanding the cosmos. The microscope has been one of the most versatile and transformative scientific instruments ever in- vented. Van Leeuwenhoek (1632–1723) made the best early in- struments, capable of 270x magnification, and became the first person to observe protozoa, bacteria, spermatozoa, blood corpus- cles, and blood circulation through capillaries. Biology was trans- formed as a result. The next revolutionary advance in microscopes in the 1930s using beams of electrons instead of beams of light allowed very small objects such as viruses, chromosomes, and nucleic acids (including deoxyribonucleic acid) to be observed, and biology was transformed once again.
Many recent advances in science would obviously be impossible without the electronic computer. Advances in brain imaging, ge- netics, and particle physics, for example, require massive amounts of data processing in addition to highly sophisticated technological equipment. Recent “big science” projects such as the Human Genome Project and the Large Hadron Collider will actually generate more scientific data by several orders of magnitude than what has been collected in all of prior human history (Hey & Trefethen, 2003). Such capabilities are even transforming the way science is conducted in these areas. Instead of the traditional approach, which can be summarized as “Hypothesize, design and run experiment, analyze result,” the new approach involves “Hy- pothesize, look up answer in database” (Lesk, 2004, p. 1).
Recent improvements involving instrumentation, measurement, infomatics, and mathematical modeling are having a revolutionary impact on the neurosciences in particular. For example, the very high spatial and temporal resolution in magnetoencephalography (MEG) brain scanning is making it possible to make highly precise measurements of neuronal activity–(the difference between MEG and functional magnetic resonance imaging is analogous to watch- ing brain activity with a high resolution video camera compared with a series of poorly focused still photos). Instead of investigat- ing psychological phenomena from the perspective of “bottom-up” connections from one neuron to the next, or “top-down” models such as the organization of intelligence through the factor analysis of IQ test data, for the first time it is becoming possible to investigate comprehensive, detailed, multilevel models that simul- taneously combine both bottom-up and top-down approaches in one model (Wood et al., 2006).
Given the complexity of psychological phenomena and the limited scientific tools that have been available to study them, it is
completely understandable that science is only now beginning to unravel the nature of more complex psychological processes. In hindsight, it was perhaps inevitable that many different explana- tions would be offered to explain the tremendous biopsychosocial complexity of human psychology, just as there were many diverse explanations offered to explain gravity, electricity, magnetism, heat, light, and sound when the physical sciences were young (Kuhn, 1962). Because of the lack of a single scientific paradigm for understanding psychological phenomena, Kuhn concluded that psychology was an “immature,” preparadigmatic science. Charac- terizing psychology in this way emphasizes the underdeveloped state of theory in the field but fails to emphasize the reasons for that underdevelopment. PP may still be in its preparadigmatic stage of development, but the reasons primarily involve the com- plexity of the subject matter and the limited scientific tools that have been available. Less complex phenomena will naturally be described and explained before more complex phenomena. If the human mind and brain truly are the most complex systems in our universe, it is only natural that they are understood in less detail than other less complicated classes of natural phenomena.
Because of the above reasons, the traditional theoretical orien- tations have not been able to adequately explain the complexity of human psychology. Psychological science has been advancing steadily, however. The question now facing the field is whether the science of psychology has advanced sufficiently that a solution to this problem is now available.
Is a Single Unified Theory the Solution for Psychology?
The discovery of a single, unified theory that successfully ex- plained human development, functioning, and behavior change would obviously bring PP out of its preparadigmatic stage of development. There have been many calls over recent decades for a unified theory that would solve the preparadigmatic theoretical confusion in psychology (e.g., Anchin, 2008; Magnavita, 2006; Sternberg, 2005). There are clear reasons, however, why such a theory is unlikely to emerge in the near future. The experience of the other sciences suggests why.
Physics is the oldest of the sciences (more than 2 millennia old) and has certainly been successful in explaining a wide range of natural phenomena from the exceedingly small (e.g., subatomic particles) to the very large (e.g., the cosmos). Despite all its achievements, however, physics has not yet discovered a unified theory that explains matter and energy. In fact, there are critically important aspects of the physical world about which very little is known, from the level of particle physics to the cosmos (e.g., 95% of the universe consists of “dark matter” and “dark energy” about which very little are known; Randall, 2011). The discovery of a unified theory of matter and energy is regarded by many as the ultimate goal of physics, but the field may still be a long way from reaching that goal (Mitchell, 2009).
Biology is a much younger science than physics but has also been highly successful. Biology was largely a descriptive science until Darwin’s 1859 On the Origin of Species, and it took until the 1930s and 1940s before the full significance of natural selection was appreciated (Quammen, 2006). Modern evolutionary theory is continuing to develop (Larson, 2004), and there is obviously a great deal about many biological processes that still remains to be
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discovered. There is some excitement that the West, Brown, and Enquist metabolic scaling theory may bring biology together under one unified theoretical framework, but that possibility is still far from being proven (Mitchell, 2009).
Despite being very well-established and successful disciplines, physics and biology have not yet discovered unified theories for explaining phenomena within those fields. In contrast, psychology is a much younger discipline that investigates extraordinarily com- plex phenomena. The power and precision of scientific tools have been advancing, but clearly much remains to be done to unravel the complexity of human psychology. There is no reason to expect that a unified theory will be discovered in psychology before one is discovered in physics or biology.
It is critical to recognize, however, that a unified scientific theory of psychology is not necessary for psychology to leave behind its preparadigmatic past. There are now no unified theories in physics, chemistry, or biology, but those fields are all viewed as solidly scientific. It is also not necessary to explain all phenomena within a particular area for a field to be considered scientific. Take the case of medicine. Certainly the success of the biomedical sciences is impressive. Nonetheless, the amount that remains to be discovered is substantial. For example, there remain a large num- ber of idiopathic diseases for which the causes and cures are unknown (e.g., Alzheimer’s and Parkinson’s disease, most sei- zures, multiple sclerosis, rheumatoid arthritis, Type I diabetes). Concern is also growing about the safety of many medical proce- dures and the widespread use of tests and interventions that may cause more harm than benefit (e.g., Institute of Medicine, 2000; U.S. Preventive Services Task Force, 2012).
The point at which medicine in the U.S. reached the “tipping point” when it most clearly transitioned from primarily an art to a science was in 1910 when Abraham Flexner submitted his report on the state of medical education. Biology had been making many important advances and the practice of medicine was transforming dramatically at the end of the 19th century. In 1878, Pasteur introduced the germ theory of infection and in the following year tested the first vaccination. Sterilization of medical instruments had been introduced and was becoming widespread toward the end of the century—(before antiseptic methods were introduced, death rates following amputations, for example, reached 100% for some physicians; Porter, 1997). To evaluate whether American medical education was sufficiently science-based, Flexner visited and rated nearly every one of the 168 medical schools in the U.S. and Canada. His highly influential report included his ratings and often scathing criticisms of the individual schools, and several of them closed soon after as a result. Over the next decades, 42% of the schools closed, and the schools that remained had significantly increased their admission standards and laboratory and clinical training requirements (Hiatt & Stockton, 2003).
Enough was discovered in physics, chemistry, and biology that those fields long ago reached the tipping point when they became considered scientific (and paradigmatic in the Kuhnian sense). Unified theories for explaining phenomena within those disci- plines clearly had not been discovered, but enough verified expla- nations of important phenomena had accumulated, and these in turn enabled the applied fields of engineering and medicine to be practiced in an increasingly safe and effective manner.
Psychology has been on a developmental course similar to that of the natural sciences. Psychological science has been advancing
steadily, and PP is increasingly embracing the need to base clinical intervention on reliable research evidence. Indeed, APA officially endorsed the evidence-based approach to clinical practice in 2005 (APA, 2005). Nonetheless, confusion persists regarding the appro- priate theoretical and scientific foundations for practicing psychol- ogy. The question now facing PP is whether the field has reached the tipping point where its practitioners can converge around a unified science-based approach to PP education, practice, and research.
The Solution: A Metatheoretical Framework
The answer to this question depends on whether psychological science has progressed sufficiently to be able to provide a unified scientific approach to clinical practice that can replace the diverse assortment of irreconcilable theoretical orientations that have his- torically guided case conceptualization and intervention in the field. If PP is ready to make this transition, it would, of course, represent a major milestone for the field. But what would the new approach look like?
As was just noted, it is not currently possible for a true unified theory of psychology to provide the foundation for unifying PP around a single scientific approach—such a theory is unlikely to be discovered for a very long time (if ever). Instead, the solution to this problem is (naturally) the same as it was for the natural sciences. When it comes to discrete, less complex phenomena, scientific laws and theories are often able to explain the processes involved. Explanations of highly complex phenomena involving many variables and processes are frequently not yet available, however. As a result, metatheoretical frameworks and models are needed to integrate what is known and provide approximate ex- planations of these phenomena (Mitchell, 2009; Rodgers, 2010). Metatheoretical frameworks attempt to identify the most essential characteristics that need to be integrated to understand complex phenomena, and specific models built from these metatheories can then be empirically tested and refined. Whether it be the climate, the behavior of galaxies or subatomic particles, or the development of personality disorders, the refinement of these models results in increasingly more complete and accurate explanations of phenom- ena.
At the metatheoretical level, the outlines of the framework needed to understand human psychology are clear. At the most general level, there is no disagreement across the sciences and humanities that human psychology is determined by a range of psychological, sociocultural, and biological factors that interact through complex developmental processes. The influence of spe- cific factors varies dramatically depending on the phenomenon and the developmental, environmental, and other contextual factors involved, and of course more is known about some phenomena than others. But taken together, the amount that is known is extensive. Psychologists are probably in agreement that all the major “waves” of theory development in the field (e.g., psychody- namic, behavioral, humanistic, cognitive, systemic, multicultural) have contributed important insights into understanding human psychology, but that these insights also need to be integrated with those from the neuro- and biological sciences, the various social sciences, and the humanities to gain a comprehensive understand- ing. Of course, the integration of all these perspectives is stagger- ingly complex and will require a huge amount of additional re-
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search. At the general metatheoretical level, however, there is unanimity that human psychology cannot be understood without taking a comprehensive, integrative approach that spans the bio- logical, psychological, and sociocultural levels of natural organi- zation.
Again, the question is not whether all of human psychology can now be explained with precision and detail, but whether enough is known to justify a transition away from the clearly incomplete and inadequate theories of the past to a single, unified, science-based metatheoretical orientation. Psychological phenomena are obvi- ously tremendously complex and the amount that remains to be discovered is huge, to be sure. Nonetheless, a great deal is now known. Is it enough to justify a general transition away from practicing psychology primarily as an art where one selects from among a diverse array of theoretical orientations, and instead move to a unified science-based approach that essentially includes just one metatheoretical orientation?
The evidence for a unified science-based metatheoretical frame- work for psychology is overwhelming. At its most general level, this framework would be based on a biopsychosocial perspective. This perspective was described by George Engel in 1977, though other terms or frameworks could be used to reflect this perspective (e.g., Bronfenbrenner’s, 2001 bioecological approach). Whatever term or framework is used, it needs to encompass the biological and sociocultural levels of natural organization that are just below and above that of human psychology. Human development and functioning simply cannot be explained without capturing the interaction of all three of these general levels of natural organiza- tion. The term biopsychosocial is widely known and accepted throughout health care and human service fields (e.g., see APA, 2006), and the biopsychosocial framework has been incorporated into medical education throughout the U.S. and Europe (Frankel, Quill, & McDaniel, 2003). It has also been adopted within several of the clinical specializations in PP (e.g., in child, school, health, and addiction psychology, neuropsychology, and geropsychology; see Martin, Weinberg & Bealer, 2007; Seagull, 2000; Shah & Reichman, 2006; Suls & Rothman, 2004; Williams & Evans, 2003). Therefore, it is a strong candidate for the basic scientific framework needed in the field.
The practice of psychology has revolved around the traditional theoretical orientations throughout its history, however, and re- placing those as the predominant frameworks for conceptualizing clinical practice would involve a major readjustment for many psychologists. For generations, students and psychologists have had to answer questions about their chosen theoretical orientations, and many clinicians would consider it completely foreign to con- ceptualize cases in a manner that did not revolve around those orientations. If the field were to abandon these practices and transition to a unified biopsychosocial metatheoretical orientation, what would that orientation look like and what would replace the traditional practices?
Implications of a Unified Biopsychosocial Approach to PP
The impact of a unified science-based approach on PP educa- tion, practice, and research would be much greater in some areas than in others. For example, the standard psychosocial history and multiaxial Diagnostic and Statistical Manual diagnosis already
require that information regarding all three biopsychosocial do- mains be collected, evaluated, and integrated. Other practices would change markedly, however. Several of these issues have been discussed extensively in the specializations that already rely heavily on the biopsychosocial approach (e.g., child, school, health, and addiction psychology, neuropsychology, and geropsy- chology). They have been discussed far less with regard to the general practice areas, however, or for PP as a whole (for recent exceptions, see Henriques, 2011 and Melchert, 2011). Below are several issues that would need to be discussed as part of a sys- tematic transition to a unified science-based biopsychosocial ap- proach for PP as a whole.
1. Only One Theoretical Orientation for Conceptualizing Clinical Practice in Psychology Would Be Taught
Many PP education programs currently take a survey approach to teaching the traditional theoretical orientations while other programs emphasize the theoretical orientations of their faculty. Taking a science-based biopsychosocial approach to understand- ing psychology results in a very different curriculum, however. From this perspective, neither individual clients nor demographic and diagnostic groups can be understood without taking a com- prehensive, integrative biopsychosocial approach. Therefore, stu- dents would no longer learn to conceptualize cases according to a chosen theoretical orientation, but would instead learn to concep- tualize cases according to a biopsychosocial approach. Particular ramifications of this perspective are discussed below.
2. PP Would Become More Clearly Oriented Around Being a Health Care Profession
PP has frequently been conceptualized as primarily a service industry where clients interested in obtaining psychological ser- vices can choose a clinician whose services and orientation are consistent with the individual’s preferences and needs (Melchert, 2011). In contrast, governments license psychologists as health care providers responsible for meeting the behavioral health needs of the public and insurers reimburse psychologists for the health care services they provide. Defining PP as a health care profession emphasizes its role as an applied science that is based on science and professional ethics. From this perspective, psychologists ad- dress patients’ behavioral health needs and work to improve their biopsychosocial functioning using interventions that have been evaluated for safety and effectiveness.
3. A Comprehensive, Holistic Perspective on Behavioral Health Care Emphasizes Functioning Broadly Across the Important Domains Of Life
Given the interactions across the psychological, sociocultural, and biological domains, a comprehensive, holistic view of human psychology emphasizes individuals’ functioning across all the biopsychosocial domains. Many of the traditional theoretical ori- entations focused on particular psychological factors (e.g., cogni- tive therapy for depression, behavioral therapy for fear and anxi- ety, client-centered therapy for low self-worth). Taking a holistic biopsychosocial perspective certainly maintains an emphasis on
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psychological factors, but also broadens the focus of assessment and treatment to physical health as well as functioning within the family, school and work settings, and community.
A useful starting point for gaining a comprehensive understand- ing of the behavioral health needs and biopsychosocial functioning of the public is an epidemiological perspective. To illustrate the implications of this perspective, the prevalence data reported in the Diagnostic and Statistical Manual (American Psychiatric Associ- ation, 2000) finds that the most common problems experienced by the general public involve sexuality (i.e., hypoactive sexual desire and orgasmic disorder in females, premature ejaculation in males) and nicotine and alcohol dependence (all of which are more prevalent than major depression, the next most common disorder; Melchert, 2011). In addition, nearly 50% of the U.S. population lives with a chronic health condition that requires routine treatment and/or activity limitations (Partnership for Solutions, 2004). The data regarding relationship problems, parenting, educational at- tainment, vocational effectiveness, financial stress, and other fac- tors also indicate that large numbers of individuals are dealing with significant challenges and are not functioning optimally in several areas. Despite their clear importance to behavioral health, many of these topics receive limited attention in current PP education. A biopsychosocial perspective, on the other hand, emphasizes all these issues.
4. Teaching the Biological and Sociocultural Bases of Behavior Would Be Strengthened
A biopsychosocial approach to PP education would continue to emphasize the psychological bases of behavior but would also include more systematic coverage of the biological and sociocul- tural bases of behavior. In addition to the psychological domain, a comprehensive understanding of human psychology requires train- ing in evolutionary psychology, the neurosciences, physical health and disease, the influence of childhood, families, relationships, neighborhoods, culture, religion, educational achievement, and vocational stability. Though this type of training would be signif- icantly more extensive than what is currently offered in most PP education programs, students typically learn a significant amount regarding these topics because of their importance in clients’ lives. Their learning about these topics is often quite haphazard, how- ever, because PP education currently tends not to cover them systematically. It is important to note that the same issue applies to physical health and medicine, a comprehensive understanding of which spans all the way from molecular biology to public health and sociocultural levels. Approaches that do not take all these levels into account are limited in both explanatory power and effectiveness.
5. The Traditional Theoretical Orientations Would Generally Be Reconceptualized as Therapies
When taking a science-based biopsychosocial approach to un- derstanding human psychology, the term theory and related terms would normally be used in their scientific sense to refer to expla- nations of phenomena that have survived experimental tests aimed at verification and falsification. As a result, the traditional theo- retical orientations would generally no longer be referred to as theoretical orientations because of their inadequacies as scientific
theories (e.g., their reliance on assumptions or worldviews, their inability to be falsified; see above). However, many of the treat- ments based on these orientations provide demonstrably effective therapies for addressing behavioral health needs. Therefore, while a single unified biopsychosocial approach would be used to un- derstand human development and functioning, there is a full range of evidence-based psychologically, socioculturally, and biologi- cally oriented therapies and other interventions (e.g., support groups, physical exercise, and diet) that psychologists can safely and effectively use to address individuals’ problems and improve their biopsychosocial functioning.
6. Many Long-Standing Conflicts Within the Field Would Quickly Become Irrelevant
The historical practice of selecting a theoretical orientation to guide one’s clinical practice naturally led to competition between the theoretical camps. A unified biopsychosocial approach, on the other hand, involves a fundamentally different framework that renders much of this competition obsolete. The biopsychosocial approach integrates the best scientific evidence available regarding all the important influences on a person in order to explain the development and functioning of the whole person, at the macro level, rather than focus on particular midlevel psychological pro- cesses as have many of the traditional theoretical orientations. This approach is tremendously complex, to be sure. But this complexity is unavoidable because human nature is simply very complicated.
The biopsychosocial approach relies on the accumulation of scientific knowledge regarding all of the many different influences on human development and functioning. From this perspective, all levels of natural organization are important, all perspectives that help explain psychological processes are valued, as are all thera- pies and other interventions that are demonstrated to improve biopsychosocial functioning. Traditional conflicts about the supe- riority of particular theoretical orientations, the relevance of re- search to practice, the superiority of qualitative versus quantitative research, or untested claims regarding the etiology of psychopa- thology or the mechanisms that account for therapeutic change all quickly fade in importance when a comprehensive science-based approach is applied.
7. Psychology Would Be Better Able to Integrate Into the Health Care Professions
Integrating behavioral health care into primary health care has recently become a priority for many psychologists (APA Presiden- tial Task Force on the Future of Psychology Practice, 2009; Good- heart, 2010). This is occurring at the same time that medicine is increasingly recognizing the importance of behavior and lifestyle to physical health and disease (e.g., Institute of Medicine, 2004). Improving the overall health of the general public will require that mental health, behavior, and lifestyle issues are more effectively addressed in health care generally, and this may in turn require that psychologists become better integrated into primary health care.
Taking a biopsychosocial approach to PP education and practice will not only facilitate such integration, it may even be necessary before psychologists can easily integrate into primary health care. Traditional approaches to PP that revolve around theoretical ori- entations are often not easily understood by medical health care
17UNIFIED SCIENTIFIC FRAMEWORK
professionals and the other stakeholders in health care systems. The biopsychosocial approach, on the other hand, is quite familiar to other health care and human service professionals. Sharing a general conceptual framework is important to the successful inte- gration of PP into primary health care.
Conclusion
The science of psychology has advanced significantly in recent years. Despite the very large amount that remains to be discovered, the available evidence overwhelmingly points to a comprehensive, integrative biopsychosocial approach for understanding human psychology. PP as a whole has not yet systematically adopted this perspective and instead continues to rely on many past practices associated with adopting one or more of the traditional theoretical orientations. The time has come to evaluate whether PP should discontinue those practices and replace them with a unified science-based biopsychosocial approach to education, practice, and research in the field. Given the inexorable progress of science, this is likely a question of when this transition will occur rather than if it occurs.
Adopting a unified science-based approach to understanding human psychology will allow PP to leave behind its preparadig- matic past, a period marked by large amounts of conflict, conten- tion, and controversy. Many of those conflicts and controversies are outdated at this point because the biopsychosocial complexity of human psychology is simply far greater than what the traditional theoretical orientations (even when combined) are able to capture. Those conflicts and controversies have caused a great deal of distraction and inefficiency, and leaving them behind will provide significant relief for the field as well as allow time and energy to be focused more productively on improving our understanding of human psychology and improving behavioral health care effec- tiveness. There is not enough space here to illustrate how more detailed explanations of the links between biopsychosocial pro- cesses are leading to a more complete understanding of human development, functioning, and behavior change, but interested readers are referred to several fascinating programs of research that are making major contributions to informing human psychol- ogy and behavioral health care (e.g., Davidson & Begley, 2012; Kahneman, 2011; Porges, 2011; Sroufe, Egeland, Carlson, & Col- lins, 2005).
Psychologists’ expertise spans all the biopsychosocial domains of functioning. We are naturally situated at the intersection of these three levels of natural organization and are very knowledgeable regarding the interplay of mental and physical health, of family and sociocultural influences on physical and mental health, and the myriad other interactions between the biopsychosocial domains. As a result, the profession is in a natural position for leading efforts to improve health and well-being in general. Entering the paradig- matic era in PP will not only facilitate this type of leadership, it may very well be necessary for moving ahead effectively in this direction. If the profession is successful in this regard, PP is on the verge of entering a truly exciting period in its development.
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Received December 16, 2011 Revision received March 17, 2012
Accepted March 23, 2012 �
19UNIFIED SCIENTIFIC FRAMEWORK
PHILOSOPHICAL EXPLORATION
Chassidic Teachings and Modern Psychology: Toward a More Unified Approach
Akiva Turner1
Published online: 28 October 2015 � Springer Science+Business Media New York 2015
Abstract This article describes how many modern psychological constructs and theories exist in older as well as newer Chassidic and Jewish teachings, particularly those of
Chabad Lubavitch. This exploration points toward a potential benefit for a unification of
psychology and Chassidic teachings. Psychological theories and constructs explored are
Freudian psychoanalysis, cognitive dissonance, cognitive restructuring/reframing, self-ef-
ficacy/planned behavior, and logotherapy/existentialism. The article then concludes with a
discussion of possible implications of moving toward a unified approach for clinical
practitioners.
Keywords Chassidus � Psychology � Behavioral change theory � Clinical practice
Introduction: Inching Away from Duality to Unity
When researchers and philosophers conduct research on or write about spirituality/religion
and mental health, they often assume a duality between the spiritual and the physical.
Reportedly, this duality grew out of the development of science and medicine overtaking
the role of the religious practitioner as healer in the middle of the nineteenth century.
Before that time, some religious practitioners may also have served as a medical and
psychological practitioner and in some cases may have had both religious and medical
training (Rosner 2001). In other words, prior to the nineteenth century, science/medicine
and spirituality/religion were not necessarily divorced. With the nineteenth-century sepa-
ration, medicine/science became skeptical of spirituality/religion, and it was not until later
in the twentieth century that medical science retook an interest in the impact of spirituality/
religion on healing (Rosner 2001).
& Akiva Turner [email protected]
1 Health Care Sciences Department, Nova Southeastern University, Fort Lauderdale, FL, USA
123
J Relig Health (2016) 55:973–985 DOI 10.1007/s10943-015-0145-z
In discussing this renewed interest by medicine/science in spirituality/religion, Rabbi
Jacobson (2014) categorizes views on the matter into three camps: (1) those who maintain
a rigid distinction between science/medicine and spirituality/religion with science/medi-
cine trumping, (2) those who reject science/medicine in favor of spirituality/religion, and
(3) those who argue a mutuality between the two with spirituality/religion serving as a
complementary therapy. Rabbi Jacobson, a Chassidic Lubavitcher Rabbi, rejects all three
of these camps and instead proposes that such a duality is objectively nonexistent. This is
because Judaism recognizes a Divine unity in which body and soul are joined into one
seamless healing process. Rabbi Jacobson describes the unified patient (body and soul)
who reflects, and indeed in Chassidic thought, is connected with, the unity of the Divine.
Recent medical and scientific research on Judaism and mental health, though sparse, has
mostly, but not completely, abandoned the first camp that makes a rigid distinction
between mental health and religion/spirituality. Moreover, few medical and scientific
researchers would accept the second approach which would mean a complete abandonment
of western medical or scientific mental health practices for spiritual/religious ones
exclusively. However, most contemporary perspectives seem to reflect the third approach
and explore or accept a dual complementary role for evidenced-based medical practices
and spirituality/religion. Even Rosner (2001) who describes the breakup of spirituality/
religion from science/medicine seems to advocate a dual or complementary approach but at
the same time acknowledges that spirituality/religion is more than rituals or views on the
world but is a way of being.
In a literature review of the dearth of research on health issues, including mental health
issues, specifically among Chassidic Jews (Chassidim), the authors emphasize how
Chassidim incorporate religion into understanding and explaining illness (Coleman-
Brueckheimer and Dein 2011). That is not surprising since for Chassidim, everything
comes from a Divine source, even illness and the ability to heal. The authors then go on to
describe how these beliefs can impact the clinical encounter, and after noting some positive
effects of these beliefs, lean toward a complementary approach (Coleman-Brueckheimer
and Dein 2011). Other research about Judaism/Jewish spirituality and health, though not
specific to Chassidim, has also focused on how religious beliefs can impact health
including depressive symptoms (Krumrei et al. 2013; Rosmarin et al. 2009a, b).
In this article, focusing primarily on Lubavitch Chassidic teachings (Chassidus), I will
attempt to move away from duality and explore the unity and connections between
Chassidus and modern psychological and behavioral thought. I then discuss some impli-
cations of Jacobson’s Divine unity of psychology and Chassidus for mental health practice.
In doing so, I am not at all trying to say that Chassidus is mere psychology or belittling its
Divine source. Some have cautioned that by discussing the therapeutic aspects of religion/
spirituality, one runs the risk of trivializing religion (Sloan et al. 2000). That is not my
intent.
Still others are concerned that any attempts to explore this unity must begin with a
moral foundation not found in the secular workings of psychology. Rabbi Alter Metzger
describes the concern this way. ‘‘Modern psychology has made a value system from a non-
value system….If Chassidus is to be reconciled with psychology it must be a psychology which rests on a moral foundation’’ (Drob 1988, p. 1). Given this, any psychology which
could be of use may have to at a minimum not deny, and at best rest upon, this moral
foundation.
Before launching into my explanation of how many or some modern psychological and
behavioral theories already exist in Chassidic teachings, I should also caution that I do not
974 J Relig Health (2016) 55:973–985
123
claim to have achieved Rabbi Jacobson’s goal of reaching unity but have only taken a step
away from duality moving toward understanding, with human and written limitations.
The Lubavitch Chassidic Movement
My focus here is exclusively on the Lubavitch Chassidic movement (Chabad). Chabad is a
worldwide movement. It is not insular but is very engaged in the outside world. Chabad sends
young married couples as ‘‘emissaries’’ to many countries with the mission to establish
‘‘Chabad Houses’’ which may serve as synagogues and community centers, often initially
beginning in the couple’s home. These couples make the sacrifice to leave the comfort and
support of their family andOrthodoxcommunity to set up and run these houses and synagogues.
They are sent as shluchim (messengers) of the Lubavitcher Rebbe who I describe below.
The goal of establishing the Chabad House was to provide a light of Jewish practice and
life for Jewish travelers and residents regardless of level of Jewish observance. These
Chabad Houses/synagogues are located all over North America, South America, Europe,
Asia, and Africa. However, the center of Chabad is found in the Crown Heights neigh-
borhood of Brooklyn, New York.
Chabad is simultaneously a community, an organization, and a movement. It is
described as a ‘‘system of Jewish religious philosophy, the deepest dimension of G–d’s
Torah, (that) teaches understanding and recognition of the Creator, the role and purpose of
creation, and the importance and unique mission of each creature. This philosophy guides a
person to refine and govern his or her every act and feeling through wisdom, compre-
hension and knowledge’’ (Chabad n.d.).
The founder of the Chabad movement was Rabbi Schneur Zalman of Liadi who lived
from 1745–1812. Known as the ‘‘Alter Rebbe’’, he is the author of the Tanya. The Tanya is
sometimes described as a book of Jewish ethics and philosophy, but it is much more. It is a
‘‘compilation of Jewish mystical concepts. (T)he Tanya presents a systematic approach,
both to an individual’s moral and spiritual development, and to a conceptual awareness of
Divine immanence….The Tanya provides a philosophical foundation in which the intel- lectual, spiritual, and psychological aspects of Jewish life are grounded’’ (Abramson n.d.).
The seventh Chabad Rebbe is Rabbi Menachem Mendel Schneerson who physically
passed away in 1994. He is simply called ‘‘the Rebbe’’ by Chabad Chassidim, and his
teachings are of major influence in their lives. In seeking resolution to life’s issues and
problems, Chabad Chassidim may search first to see whether the Rebbe had something to
say about the matter and may even pray at the ‘‘Ohel’’ (tent) located in Montefiore
Cemetery in New York where the Rebbe and his father-in-law, the previous Rebbe, are
interned, asking that the Rebbes intercede with the Divine on their behalf.
In addition to his religious background, the Rebbe was university educated in science,
mathematics, and engineering. For the Rebbe, Torah and science are unified, and when faced
with what appeared to be a contradiction between the two, the Rebbe once responded, ‘‘It is
not science per se but the men of science who may state as fact something that contradicts
(Torah). In the process of clarifying and trying to understand the truthfulness of science, men
of science, with their knowledge too limited, may come statements that will contradict. But
science itself is true and cannot contradict Torah.’’ (Mindel 2013, p. 199). In other words,
there is a unity that man may not have yet discerned, due to human limitations.
In this article, I will not delve deeply into the relationship and the meaning of the Rebbe
to Chabad Chassidim. It would be a lengthy essay of its own, and others have described
J Relig Health (2016) 55:973–985 975
123
that relationship elsewhere (Steinsaltz 2014; Schulman and Kaplan 2013). However,
Chabad does publish many of the Rebbe’s letters in which he provided advice to those who
sought it, in and outside of Chabad. In drawing the connections between modern psy-
chological and behavioral theories with Chassidus, I will rely upon some of the Rebbe’s
teachings reflected in these letters, the Tanya, and teachings of others influenced by both.
Freudian Psychology
A few religious and non-religious scholars have to some degree brushed against Rabbi
Jacobson’s approach to psychology by exploring consistencies between Freudian psy-
choanalysis and Chassidic Jewish thought with some seeking to historically link the
influence of Jewish mysticism on Freud himself (Wasserman 2004). They have searched
for historical connections between Freud and the Chassidic community while drawing
parallels between Freudian theory and Chassidus, particularly the Tanya.
One major theme of the Tanya is identity crisis. The Tanya delves into questions such as
‘‘(w)ho are we? Are we to ignore our beastly temptations, or come to terms with them?
And how is it that people possessing a G–dly soul can be filled with such animalistic
desires? It is Tanya that guides us through our dual personality. It gives us the insight to
understand and overcome the struggles we deal with on a day-to-day basis’’ (Cotlar n.d.).
This requires further elucidation. According to the Tanya, this dual personality is a
battle between a Divine soul and an animal soul (Zalman 1797/1982). The animal soul is
connected with physicality and is vital as we are dependent upon it for physical vitality.
The Divine soul battles the animal soul in a perpetual struggle. However, instead of
destroying the animal soul, the Divine soul overpowers it (Steinsaltz 2007).
Some have compared this struggle between the Divine and animal souls with Freud’s
description of the Id and Ego. Wasserman (2004) writes:
…(M) an’s soul is divided in half: The Animal Soul represents emotions such as rage, lust, passion, and jealousy; all of which appear to parallel with Freud’s Id: both
are understood as primal and instinctual. The Divine Soul {nefesh elokit) represents
just that: the intellect, the ‘higher’ versus the ‘lower’ parts of the soul. It includes the
Sefirot Chochmah (Wisdom), Binah (Understanding), and Da ‘at (Knowledge). The
above Sefirot are the parallels to the ego or the ego ideal. Both the Animal/Divine
Souls and id/ego are theorized to be be in perpetual conflict; both hold the Divine/ego
must assert its will over the Animal/Id in order to contend with the dark and irrational
within man (pp. 76–77).
In Chassidus, there is also described a struggle between two aspects of the soul, the
Yetzer Harah (evil inclination) and the Yetzer Tov (good inclination). The Yetzer Harah is
sometimes called the animal soul but they are not exactly synonymous. The animal soul
refers to all ten faculties of the entire soul, while the Yetzer Harah is only the seven
emotions of the animal soul.
The animal soul, the nefesh habehamit, is the source of all your self serving – but not
necessarily evil – drives. In one word, the animal soul is self-centered passion. That
doesn’t mean it is bad. It can be neutral, or even good. The yetzer hara is one’s evil
inclination. Think about what that means: your inclination to do evil. For example,
the desire to eat non-kosher food, steal money, or do anything forbidden by the
Torah. Those are all products of the yetzer hara. The word yetzer is related to the
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Hebrew word tziyur, ‘‘form.’’ In other words, the yetzer hara takes the raw material
of the animal soul’s benign passion and provides it form by channeling it towards
immoral ends (Janowski n.d.).
In applying this conflict, Berke (1996) has taken a more clinical approach and has
compared the various definitions of depression with descriptions of similar states in the
Tanya. Berke relates the struggle of the two aspects of the soul, the Yetzer Harah part of
the soul being overcome by the Yetzer Tov part of the soul as described in the Tanya, as a
psychoanalytic therapeutic approach for overcoming depression. He has also identified a
similar use of dreams in psychoanalysis and Chassidus.
Indeed, some forms of psychoanalysis may be consistent with Chassidus. Based upon the
work of Rabbi Yehudah Leib Alter of Gur (Sfat Emet), the Rohr Jewish Learning Institute
(JLI), Chabad’s educational arm, produced a lesson called ‘‘Know Thy Self.’’ (Incidentally,
the Sfat Emet’s life overlapped with part of Freud’s time, and he was alive in 1901 when
Freud’s book, The Psychology of Everyday Life, was published). The lesson ‘‘Know Thy
Self’’ describes how in Genesis Abraham sends his servant Eliezer to search for a future wife
for his son, Yitzhak (Isaac). A separateMidrash tells that Eliezer really wanted Isaac tomarry
his own daughter but Abraham refused. Being a fateful servant, Eliezer goes to Haran and
eventually finds Rivka (Rebecca). When trying to convince Rebecca and her family to agree
to the marriage, Eliezer tells them of an original conversation—which did not include the
Midrashic account of the discussion regarding Eliezer’s daughter—he had with Abraham
before embarking on this journey. Although the original conversation was also recorded
earlier in the Torah, the Torah records the complete retelling by Eliezer to Rebecca and her
family. But in the retelling, a single word is spelled differently from its spelling in the original
telling. The Hebrew word for ‘‘perhaps’’ in the phrase ‘‘perhaps the woman’’ is spelled in a
way that can be read ‘‘to me the woman’’. This change in spelling transforms the word’s
meaning and reveals Eliezer’s true desires. Commentators point to this change in spelling/
meaning as evidence that Eliezer, though faithful to Abraham, was in the midst of a sub-
conscious conflict as he still truly wanted Isaac for his own daughter (JLI 2014) In other
words, Eliezer had a slip or parapraxis (Freud 1901/1960).
The JLI (2014) authors explain that, as in psychoanalysis, the retelling of the story by
Eliezer was important because when he retells the story, he reanalyzes and relives the
conversation and thus can become aware and recognize his own subconscious desire. Once
Eliezer was aware of his conflict, he was able to complete his mission successfully. The
course ends with the following quote from the Rebbe recorded in Torat Menachem:
One of the new treatments is to explain to emotionally unhealthy people the matter
that brought them to this state which can be called ‘‘nervous’’ or ‘‘mentally sick’’ or
‘‘emotionally disturbed’’. This brings healing after identifying the reasons why ’’he is
assaulted with such emotions, one is able to now emerge from it’’ (pp. 131–148).
Cognitive Dissonance
In Chassidus, the human being is considered basically good. However, the good becomes
concealed by influences in the physical world. The mission or purpose of the Jew is to
refine the physical world to reveal the concealed Divine goodness and to elevate the
physical. This revelation of the good is a way to reach consistency. The ability to reveal
this good involves the dual aspects of the soul, the Yetzer Harah and the Yetzer Tov
(Zalman 1797/1982).
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Evil, according to Chassidus, does not have an independent existence. It is a ‘‘potential
state of being that appears to have a real existence’’ to give an individual free choice
(Jacobson 1995, p. 269). To demonstrate this concept, the Rebbe once used the example of
a knife which can be used to kill or for surgery. The Divine allows humans to choose how
they will use the knife. That choice is part of the internal struggle (Jacobson 1995).
Leon Festinger (1962) developed the theory of cognitive dissonance. This theory
describes how human beings strive to reach a state of consistency. It ‘‘centers around the
idea that if a person knows various things that are not psychologically consistent with one
another, he will, in a variety of ways, try to make them more consistent’’ (p. 93). Cognitive
dissonance is most acute when a behavior conflicts with one’s self-identity. To manage the
dissonance, one can remove oneself from, or lessen the importance of, what is causing the
dissonance or transform the conflicting influence to create a consistency (Festinger 1962).
Chassidus seems to favor the latter approach to resolving the conflict. In Chassidic
language, then, when an individual is engaged in the world and there is a struggle between
the Yetzer Harah and the Yetzer Tov, he or she is faced with choices to bring about
consistency. Chassidus suggests one can bring consistency by transforming one’s self or
one’s environment (reveal the Divine goodness to be consistent with one’s good ‘‘iden-
tity’’). At the same time, Chassidus also embraces this inconsistency and sees it as a
necessary and important step toward growth or consistency.
Shalvi Weissman (n.d.), a writer and Chassidic therapist, gives the example, among
others, of a mother who studied much about parenting and internally knew that spanking
her child would not be the best parenting approach, but gives into the external stresses and
spanks her child. To resolve the conflict between spanking and what she had learned about
the best approach to parenting, she convinces herself that she should parent in a manner
natural for her and the way her mother raised her, including spanking. In other words, the
Yetzer Harah may have temporarily won the battle. However, Weissman advises that:
Cognitive dissonance can help us streamline our beliefs in a positive way as long as
we stay focused and don’t give up because we aren’t 100 % there yet. It can pull us
down if we are not aware of its power and the rationalizations that are its trusted
helpers. Strive for your spiritual goals. When circumstances get in your way, don’t
let justifications set into dull your dreams. Growth can only happen when we allow
ourselves some inconsistency. Don’t be afraid to take a step in a good direction just
because you can’t yet see the end of the road.
Cognitive Restructuring/Reframing
Beck (1997), a psychologist interested in therapeutic approaches to depression through the
use of positive thinking, proposed the process of cognitive restructuring. He found that
patients with depression often had many negative thoughts, and he worked with them to
reframe their thoughts into positive ones as a relief to depression. Beck proposes that
emotional states are impacted by core beliefs that influence perceptions.
Chassidus teaches that everything that happens is ultimately ‘‘for the good’’ even though
it may not appear to be so at the time. This because the goodness may be beyond our
limited understanding and knowledge at this moment. Chassidim often quote a Yiddish
saying attributed to the Tzemach Tzedek, the third Rebbe of Chabad who lived from 1789
to 1866, tracht gut, vet zein gut (think good, and it will be good). All is for the good
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because all comes from a Divine source. As already noted, even evil, which exists to give
humans free choice, comes from the Divine.
A story is told in the Talmud Balvi, Tractate Berachos, 60b, about one of the great
Jewish sages, Rabbi Akiva, who lived in the first and second centuries. Rabbi Akiva was
traveling on his donkey to a village along with his rooster to wake him up in the morning
and a candle to provide light. As nighttime came, he had not made it to the village and had
to camp in the forest. During the night, his candle blew out. Then, his rooster and donkey
were eaten by wild animals. Rabbi Akiva’s response to the event was, ‘‘All that the
Merciful One does is for good.’’ The next morning, Rabbi Akiva arrived at the village.
There he was told that robbers had traveled through the forest during the night and attacked
the village. If Rabbi Akiva’s candle had still been lit, if his rooster had crowed, and/or if his
donkey had brayed, he would have been victim to the robbers.
The end result of this story is that what appears to be negative, can really be positive. As
humans, we may not have the full knowledge to realize the positive nature of what is
happening to us. However, by reframing the negative to the positive, one will have less
anxiety when things seem to be going wrong (Beck 1997). In Chassidus, this reframing is
adjusting ones thoughts to a positive objective reality that may exist beyond a human’s
limited perspective.
Contemporary Chassidic writers have incorporated this approach into much of their
advice. For example, Rabbi Jacobson (1995) wrote a widely read popular book based upon
the teachings of Chassidus and specifically upon those of the Rebbe. In one of the steps to
deal with fear, anxiety, and depression, Rabbi Jacobson tells the reader to:
Introduce a fresh perspective to your thinking….(B)egin to replace troubling, destructive thoughts with positive constructive ones…. This is not foolish optimism; this is recognizing the goodness within even a seemingly bad situation, recognizing
that battling your fear means overcoming a challenge (p. 140).
The Rebbe gives somewhat similar advice in one of his letters to a person facing what
appears to be negative setback. He advices that:
(O)ne should not become overwrought or dispirited (G–d forbid) when one observes
a descent, especially when that descent relates only to material things, and especially
since it happened through no cause of your own. Indeed, a descent ought to arouse —
from deep within oneself — greater powers of faith and trust, whose external
manifestation is a courageous spirit and a lack of emotional reaction to an unpleasant
phenomenon (Weinberg, p. 75).
Self-Efficacy and Planned Behavior
Self-efficacy is a social psychological construct and used in interventions that seek to
create positive healthy behavior change. Self-efficacy is a person’s perception of his or her
capability to change or adopt a new behavior (Bandura 1977, 1986). Having a sense of
purpose in life has been found to have a positive influence on self-efficacy (Blazek et al.
2014). However, according to Bandura (1977, 1986), repeated ‘‘failures’’ can lead to low
self-efficacy.
In Chassidus, Jews are encouraged to take on mitzvahs (obligations) to connect with the
Divine. These mitzvahs could be increasing prayer, lighting candles to welcome the
Sabbath, not working on the Sabbath and biblically commanded holidays, and placing a
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small scroll with specific passages (mezuzah) in on one’s doorways, to name a few. One is
also encouraged to live a more happy and moral lifestyle. For Jewish individuals who may
have grown up without religious observance or in less observant homes, making these
changes can be daunting. However, Chassidus teaches that the Divine never gives a person
a challenge he or she cannot overcome. This does not mean that it will be easy, only
possible. This view is not limited to mitzvahs but also in dealing with life’s difficulties
presented within relationships, family matters, health-related behaviors, and addictions.
Reminiscent of self-efficacy theory, in Chassidus how one views the attempt is as
important as a successful outcome. In fact, Chassidus finds merit in ‘‘lowliness’’ or an
unsuccessful attempt. In the Torah, it is recorded that Jacob had a dream. In that dream, he
saw a ladder. On the ladder, there were angels ascending and descending. Suppose one
angel is on a higher rung and the other angel is on a lower rung. Which is higher spiri-
tually? It depends upon which direction the angel is going. If the angel on the higher rung
started at the top, then he is on his way down. If the angel on the lower rung just started
climbing, then he is on his way up. Put simply, it is the direction that is important, not the
rung or the outcome of the attempt. (Rabbi B. Singer, personal communication regarding a
teaching of the Lubavitcher Rebbe).
In theories such as self-efficacy and planned behavior, the immediate antecedent to
behavior change is intention (Ajzen 2002). The following teaching emphasizes the
importance of intention. Rabbi Yosef Rozen (1858–1936) also known as the Rogatchover
Gaon wrote various commentaries and responsa, some of which was collected and pub-
lished as commentary on the five volumes of responsa on the Torah. In his responsa, the
Rogatchover discusses the following concept. A complex area of Jewish law in which
some border areas in Israel can be viewed as inside or outside of Israel in limited matters,
and in some opinions, depending upon the individual’s intention in the matter under
consideration. If one is intending to enter Israel, the border area is part of Israel under
Jewish law for deciding the matter at hand. If one’s intent is to leave Israel, the area is
considered outside of Israel for the matter at hand. In other words, one’s intention defines
the place. Individuals often find themselves in ‘‘borders’’ deciding where to go (e.g., truth
or falsehood, holiness or profanity, functionality or disfunctionality, happiness or
depression), but in these borders, where one is depends upon his or her intention. It is not
where you are but where you want to be. If you are suffering from addiction, anger,
dejection, fear, what counts more is where you want or intend to be. If you want to get out
of a lowly state, that desire or intent means you are not really in that lowly state any longer.
(Rabbi B. Singer, personal communication, October 4, 2014, and Rozen).
Additionally, in his letters, the Rebbe emphasized the positive power of intention:
There is also known the saying of my father-in-law…of blessed memory: ‘‘A soldier on his way to the battlefront sings a march of victory and joy,’’ although he has yet to
begin the battle. For the mindset of having firm faith and conviction in the certain
victory in the approaching battle and the joy [that will result from this victory], in
itself strengthens and hastens the victory in battle (Wineberg 2007, p. 60).
And tying the intent to self-efficacy, the Rebbe tells another person:
Thus, in the final analysis, it is up to a person to overcome his difficulties by his own
efforts and determination, and we have already been assured that where there is a
determined effort, success is certain.
Moreover, it is quite possible in your case that you have truly underestimated your
success, and your belief to the contrary, [i.e., that you have not succeeded,] is merely
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a result of a thought implanted in your mind by the yetzer hara [in order to succeed
in making you feel glum and downhearted]. …(Wineberg, pp. 32–33).
Victor Frankl and Logotherapy/Existentialism
The Lubavitcher Rebbe greatly encouraged the work of psychologist Victor Frankl.
Frankl’s views are very consistent with Chassidus, particularly his view that life always has
meaning. According to Frankl (1959/2006), life has meaning even at times of death and
suffering, something believed deeply by many Chassidim, and such life is valuable even at
its end. Frankl’s approach is based upon three concepts all consistent with Chassidic beliefs
as described throughout this article: (1) freedom of will which has its root in spiritual
dimensions; (2) pursuing meaningful goals, without which can cause depression, anxiety,
addiction, and other psychological issues; and (3) meaning in life as an objective reality,
not subjective.
At a time when Victor Frankl was very discouraged about how his work was being
negatively received by his colleagues, it is reported that he was on the verge of giving up.
However, at a decisive moment, Dr. Frankl received some unsolicited strong encouraging
advice from the Rebbe to continue and that he would prevail. The Rebbe encouraged
Frankl because his approach ‘‘fosters belief in G–d, a spiritual perspective, and good
values.’’ (Biderman n.d.)
Unity, Duality, and the Role of the Practitioner
After all the above, I cannot claim that these modern psychological theories come directly
from Chassidus. That claim would require historical research beyond the scope of this
article. Instead, I have tried to demonstrate how Chassidus, existing before the rise of
modern psychology, contains similar psychological approaches that can impact one’s
mental health, foster behavior change, and lead to a positive wellbeing. However, this begs
some practical questions, particularly about the role and status of the mental health
practitioner, and especially if the practitioner is trained in mental health but less familiar
with Chassidus.
For the Chassidic individual, his or her religion is more than prayers for healing or any
specific intervention. It is a way of life that encompasses every daily activity, 24/7. The
physicality of the mundane world conceals holiness to be revealed by the individual. Given
this, must a mental health practitioner working with a Chassidic patient be a follower of
Chassidic teachings or is it enough to be empathetic and understanding of the patient’s
belief system? In other words, can an outside practitioner appropriately work with a patient
whose life is guided by body/soul unity? Or can an outside mental health practitioner
understand and incorporate Chassidic teachings into practice sufficient enough to be
effective? Lastly, do either of these approaches represent a move toward a more unified
approach?
According to Jewish belief, practitioners and physicians receive permission to heal from
the Divine. Thus, for Chassidim to use practitioners trained in the sciences is not only
permissible but encouraged when necessary, and may even be a religious obligation.
Although the ultimate source for the practitioner’s ability to heal is Divine, this can be
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expressed through natural processes since natural processes are considered to also be
Divine.
Indeed, the Rebbe would encourage those in need to seek out the expertise of profes-
sionals trained to deal with mental health issues. He would sometimes advise individuals to
see a medical professional, including a psychiatrist. In one letter, a person wrote to the
Rebbe about a boy’s psychiatric condition, the Rebbe responded as follows:
Physical wellbeing is primarily dependent on spiritual wellbeing; one must, however,
utilize natural means [of healing] as well. [Mr. …] should [therefore first] inspect the mezuzos (scrolls fixed on a doorway) in his home as well as his tefillin (phylacteries
worn by males 13 years or older). I am referring not so much to the boxes that house
the parchments of tefillin, but to the parchments [and writing] themselves, that they
be kosher according to Jewish law. The mother of the boy should scrupulously
observe matters of tznius (modesty), most importantly with regard to the laws and
regulations of family purity. Prior to lighting candles erev Shabbos and erev Yom Tov
as well as every Monday and Thursday during the week, his wife should give several
francs to tzedakah (charity). Their son should wear a tallis kattan (a four cornered
garment with strings) and be scrupulous about keeping his head covered. In addition
to all the above, they should seek the advice of a noted psychiatrist from a large city
and follow his instructions (Wineberg, pp. 87–88, parenthetic translations added).
In another case, he advised someone to make sure an individual was actually seeing a
psychiatrist for his condition.
… Enclosed is a copy of my response to Mr. … Since he is unaware that I have sent you a copy, you on your part should try to find out in a diplomatic manner whether
they visited a psychiatric specialist, what he said to them, and whether she is obeying
and following his instructions. …Certainly there are eminent specialists in this field in your locale, and it is worth making an effort that they seek out the advice of one of
them, as the matter about which he writes, unfortunately, is not all that uncommon in
someone whose mental health is unstable (Wineberg 2007 p. 152).
In another case, he even agreed with hospitalization for mental illness, but note that the
reason for the hospitalization is in order to receive the blessings of the Divine.
…Understandably, in such a situation, you are to follow the directive of the specialist about whom you write, [i.e., that your daughter be hospitalized,] for this will also
benefit your daughter tichye — surely she will be unable to receive all the benefits
and care [at home] that she can receive in the surroundings suggested by the doctor.
However, before you [hospitalize her], you must find out more details about the
particular institution; specifically, to establish a connection with the physician there,
so that you will know what is transpiring with her, and most importantly — and this
is easy to understand — that you be able to be certain that she is receiving the
required attention and not treated in an indifferent manner. May it be the will of G–d,
‘‘Healer of all flesh and Performer of wonders,’’ that your actions on your daughter’s
behalf act as the conduit through which to receive G–d’s blessings, as the verse
states: [‘‘G–d will bless you] in all that you do’’ (Wineberg 2007 p. 137).
At other times, practitioners would also seek the Rebbe’s advice. For example, a
therapist once sought the Rebbe’s blessing in helping a patient. The Rebbe responded:
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I will mention you in prayer and for a blessing at the holy resting place of my father-
in-law…that you succeed in your treatment of the above patient as well as all the other patients whom you assist. With regard to your seeking advice: This is, after all,
your profession, and there are none so wise as those who have direct experience
(Wineberg 2007 p. 146).
Clearly, according to the Rebbe, the services of a mental health practitioner can be
useful and may be even encouraged. However, he did not hesitate to advise one individual
about the type of mental health practitioner that would be unacceptable.
There is a specific class of therapists who commence their therapy by deriding G–d,
spirituality, honoring one’s parents, and the like. If that is the type of therapist he is
seeing, then even if the therapist is distinguished in his field, much examination and
clarification is required in order to ascertain whether the benefit he may receive from
him outweighs the long-time harm that may result [from this form of therapy] with
the passage of time (Wineberg 2007 p. 151).
It appears the Rebbe would accept the work of outside practitioners provided they do
not steer the patient away from a religious life.
On the other hand, therapists and scholars who have written about incorporating religion
into mental health practice have introduced varying perspectives mostly from the position
of duality. For example, two therapists working with Lubavitch Chassidic patients advo-
cate working separately from the religious authority and maintain that although the
practitioner should understand the patient’s beliefs and customs, he or she must remain an
objective outsider (Schulman and Kaplan 2013). Still others have suggested that religious
beliefs are inherent in determining whether a patient’s behavior is pathological and not a
group norm and also suggest that the outsider practitioner work with a religious authority
recognized or accepted by the patient (Greenberg and Witztum 2001). In other words,
perhaps moving toward a unified approach may require two practitioners. This could just
be another complementary dual approach unless Chassidus is incorporated into the actual
therapy and not seen as simply complementary or ancillary to the real work of the mental
health practitioner.
Another, possibly better approach would be that the therapist be an insider trained in
both Chassidus and evidenced-based mental health practices. Even if that is the best case, it
may not always be realistic. Given this, the suggestion for the practitioner to work closely
with a religious authority could come closer to a unified approach if the practitioner
understands the therapeutic strengths inherent in Chassidus and allow those to influence the
therapy to the fullest extent possible.
In fact, some research has shown that many religious communities may not access
psychological services because they desire a spiritually integrated model of care (Puchalski
et al. 2001). This has led to some success in bringing spirituality/religion into psychology
(Rosmarin et al. 2011). Thus, with an integration of a trained mental health professional
with a religious authority, some individuals may be more accepting of the therapy as at
least there would be some comfort that the approach used in the therapy would be more
appropriate.
In the end, however, whether the mental health professional perceives his or her ability
to heal to come from the Divine, according to Chassidus, as noted above, that ability and
permission to heal comes from the Divine even if the practitioner is using natural processes
or science, as they too are from the Divine. Therefore, even if a mental health practitioner
perceives himself or herself to be objective and works without the partnership of a religious
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authority, the Chassidic patient may believe the source of the mental health practitioner’s
skill to ultimately be from the Divine even though the practitioner may perceive himself or
herself ‘‘secularly’’ trained. As long as the practitioner does not deride or try to steer the
patient away from his or her religious beliefs and practices, as the Rebbe warned against, or
use methods contrary to the patient’s religion, then the patient may still benefit from the
‘‘secular’’ practitioner’s services.
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Journal of Religion & Health is a copyright of Springer, 2016. All Rights Reserved.
- Chassidic Teachings and Modern Psychology: Toward a More Unified Approach
- Abstract
- Introduction: Inching Away from Duality to Unity
- The Lubavitch Chassidic Movement
- Freudian Psychology
- Cognitive Dissonance
- Cognitive Restructuring/Reframing
- Self-Efficacy and Planned Behavior
- Victor Frankl and Logotherapy/Existentialism
- Unity, Duality, and the Role of the Practitioner
- References
Leaving Behind Our Preparadigmatic Past: Professional Psychology as a Unified Clinical Science
Timothy P. Melchert Marquette University
The behavioral and neurosciences have made remarkable progress recently in advancing the scientific understanding of human psychology. Though research in many areas is still in its early stages, knowledge of many psychological processes is now firmly grounded in exper- imental tests of falsifiable theories and supports a unified, paradigmatic understanding of human psychology that is thoroughly consistent with the rest of the natural sciences. This new body of knowledge poses critical questions for professional psychology, which still often relies on the traditional theoretical orientations and other preparadigmatic practices for guiding important aspects of clinical education and practice. This article argues that profes- sional psychology needs to systematically transition to theoretical frameworks and a curric- ulum that are based on an integrated scientific understanding of human psychology. Doing so would be of historic importance for the field and would result in major changes to profes- sional psychology education and practice. It would also allow the field to emerge as a true clinical science.
Keywords: professional psychology, clinical science, biopsychosocial, evidence-based practice
The behavioral and neurosciences have made remarkable progress in the past couple decades. Major advances have been made in understanding a wide range of phenomena, from epigenetics and neural plasticity to the nature of cog- nition, emotion, consciousness, moral reasoning, social be- havior, and culture. Indeed, so much has been learned about human psychology recently that current explanations of many psychological mechanisms and processes are mark- edly different from those considered current just a genera- tion ago.
At the same time that the scientific understanding of psychology was surging forward, however, professional psychology (PP) went through a particularly challenging period. There has always been competition and divisiveness between the theoretical camps in the field, but the serious- ness of the conflicts increased in the 1990s. The movement to establish empirically validated treatments was highly contentious and the divisiveness surrounding recovered memories of child sexual abuse was some of the most serious ever in the history of psychology (Loftus & Davis, 2006). Many leading psychologists were concerned that the conflicts and divisions had become so serious that the field might not be able to continue as a single discipline (e.g.,
Benjamin, 2001; Staats, 2005; Sternberg, 2005). The role of psychologists, counselors, social workers, and other mental health therapists in providing behavioral health care also declined from the 1990s to the 2000s while the proportion of clients with mental health problems treated by psychia- trists and general medical practitioners increased (Wang et al., 2006).
Professional psychology has made substantial progress in working through several of these issues over the past de- cade. Contemporary research tends to use stronger designs, measurements, and statistical analyses than what were used in the past, and there is less controversy regarding published research findings as a result. Widespread consensus has also developed regarding the need to apply evidence-based prac- tice guidelines when providing behavioral health care (American Psychological Association [APA] Presidential Task Force on Evidence-Based Practice, 2006). These and other developments have helped rein in issues that might have led to significant controversy in the past, and several observers have noted that conflict and divisiveness in the field have declined generally (e.g., Goodheart & Carter, 2008).
Beyond these trends, there is also a more fundamental change taking place. Recent research on human behavior has advanced so significantly that the current scientific understanding of human psychology is now fundamentally different from many of the standard approaches PP tradi- tionally used to understand human development, function- ing, and behavior change. For example, PP education has
Correspondence concerning this article should be addressed to Timothy P. Melchert, Department of Counselor Education and Counseling Psychol- ogy, 168F Schroeder Complex, Marquette University, Milwaukee, WI 53201. E-mail: [email protected]
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American Psychologist © 2016 American Psychological Association 2016, Vol. 71, No. 6, 486 – 496 0003-066X/16/$12.00 http://dx.doi.org/10.1037/a0040227
486
often relied on an array of competing theoretical orienta- tions for case conceptualization and other important aspects of clinical training, whereas these orientations are rarely mentioned in current scientific explanations of human de- velopment and behavior (these issues are all discussed more extensively in the next two sections). As a result, PP needs to reconsider the standard frameworks and curriculum it uses for education and training in the field. PP needs to keep current with the underlying science, and outdated frame- works and practices need to be identified and replaced based on the best scientific evidence available.
The main question addressed in this article concerns whether PP needs to undergo a fundamental transition from the era when the traditional theoretical orientations provided the main conceptual foundations for clinical education and practice to an era based instead on an integrated scientific understanding of human psychology. Such a transition would be of historic importance for the field and would result in major changes to PP education and practice. Eval- uating whether such a transition needs to take place, how- ever, requires an appreciation of the nature of theory and research in the field. Therefore, this article begins with a brief historical review of theory and research in psychology, so that the earlier approaches can be contrasted with the current scientific understanding of human psychology.
Professional Psychology in the Preparadigmatic Era
A wide variety of theoretical approaches have been used to understand human development, functioning, and behav- ior change across the history of PP. Understanding the
reasons for this diversity of approaches is important for appreciating the evolution and current status of the field.
The Proliferation of Theoretical Orientations
When psychology was becoming established as a scien- tific discipline in the second half of the 19th century, there were two main approaches to understanding mental phe- nomena. The first of these was mental philosophy. The work of John Locke (1690), who proposed the conceptual- ization of the mind as a tabula rasa, or blank slate, in 1690, was particularly influential. The second main approach in- volved the experimental methods that emerged from the scientific revolution, including the anatomical and physio- logical investigations that were being conducted in biology and medicine (e.g., Hermann Helmholtz’s 1850 discovery of the speed of nerve conduction and Paul Broca’s 1861 discovery of a brain lesion in a man who had lost the ability to speak; Benjamin, 2014). Fechner’s 1860 Elements of Psychophysics proved to be a watershed in convincing scientists that it was possible to reliably measure psycho- logical, and not just physiological, phenomena and that a science of psychology was consequently possible.
Over the next century, a wide variety of alternative ap- proaches to understanding human psychology were proposed. Freud proposed that it was actually subconscious processes, rather than the conscious mental processes most psychology researchers focused on, that were the important forces driving human psychology. John Watson then argued that neither conscious nor subconscious phenomena were the proper focus of psychology and should be replaced with a focus on behav- ior. Starting in the 1950s, humanistic theories and, later, cog- nitive and family systems approaches quickly grew in popu- larity. In the 1970s, feminist and multicultural approaches became influential, followed by solution-focused therapy, eye movement and desensitization reprocessing, mindfulness- based approaches, motivational interviewing, and others. Com- bining orientations in an integrative or eclectic fashion also became common in the 1990s and new theoretical systems continue to be proposed (e.g., Henrique, 2011; Magnavita & Anchin, 2014).
The problem of irreconcilable theoretical orientations for understanding psychological phenomena was recognized right from the start. The most influential critique came in 1913 from John Watson, who pointed out that the existing theoretical orientations fundamentally conflicted in ways that were not resolvable (Watson, 1913). Thomas Kuhn’s (1962) model of the evolution of scientific disciplines is often used to explain this complicated situation. Kuhn con- cluded that psychology was in a preparadigmatic stage of development characterized by many conflicting views and competing explanations for phenomena and disagreements about what is even the proper focus of research. Kuhn argued that a field becomes paradigmatic after the emer-
Timothy P. Melchert
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487UNIFIED CLINICAL SCIENCE
gence of a major scientific achievement or school of thought (i.e., a paradigm) that convincingly explains phenomena and unites the scientific community in an area.
There are still many signs of preparadigmatic conflicts and practices in contemporary PP. Divides between theo- retical camps remain serious (e.g., Shedler, 2010; Sternberg, 2005; Wampold et al., 2010), and none of the theoretical orientations have come to dominate PP or the larger behav- ioral health care field. Surveys of behavioral health profes- sionals consistently find that only a minority, typically less than one third of the sample, endorses a particular theoret- ical orientation, even an eclectic or integrative approach (Prochaska & Norcross, 2014). There have also been con- cerns that the use of some theoretical orientations is poten- tially harmful. The use of unreliable techniques or unsup- ported interpretations involving recovered memories of child abuse resulted in numerous allegations of harm in the 1990s (Loftus & Davis, 2006), and concerns have been raised about several other orientations to clinical practice as well (Lilienfeld, 2007; Norcross, Koocher, & Garofalo, 2006).
Given the diversity of competing theoretical orientations in PP, the standard approach for therapists to show that their clinical services are competently delivered has been to select a theoretical orientation and learn to apply it consis- tently in practice. This approach is still evident in current educational practices in the field. For example, the Ameri- can Psychological Association (APA) Assessment of Com- petency Benchmarks Work Group (Fouad et al., 2009) identified one of the “essential components” of competent practice as follows: “Formulates and conceptualizes cases and plan interventions utilizing at least one consistent the- oretical orientation” (p. S19). To apply to internships listed by the Association of Psychology Postdoctoral and Intern- ship Centers (APPIC), students need to answer the follow- ing question on the APPIC Application for Psychology Internship: “Please describe your theoretical orientation and how this influences your approach to case conceptualization and intervention” (APPIC, 2015).
Reasons for the Preparadigmatic Proliferation of Theoretical Orientations
Though it may seem unusual that a diverse array of competing theoretical orientations for understanding phe- nomena would develop within a scientific discipline, there are very understandable reasons why this happened in PP. Many of these reasons are generally well known. In addition to the different personalities of the theorists and the differ- ent historical and cultural contexts in which they worked are issues more directly related to the nature of scientific theory and research. Four issues are particularly important in this regard (Melchert, 2015).
First, many of the traditional theoretical orientations in the field are based on philosophical assumptions or first principles (e.g., biologically based drives in Freudian theory, the blank slate of nearly complete malleability in behaviorism, an opti- mistic self-actualizing tendency in Rogerian theory, a post- modern constructivism in solution-focused therapy). As a re- sult, accepting the validity of these theories is based largely on accepting their underlying assumptions. Indeed, advice on selecting a theoretical orientation to guide one’s ap- proach to clinical practice frequently involves evaluating the fit between the personal worldview of the therapist and the assumptions underlying a theoretical orientation (e.g., Truscott, 2010).
A second reason for the preparadigmatic nature of psychol- ogy involves the problem of nonfalsifiability, which was iden- tified by the philosopher of science Karl Popper. As a student in Vienna in 1919, Popper heard both Freud and Einstein present their theories. Though he was highly impressed with both of them, he observed that Freud’s was presented in a way that made it amenable to confirmation, whereas Einstein’s had testable implications that, if shown to be false, would prove the entire theory wrong. Popper (1963) argued that scientific the- ories must be falsifiable, and genuine tests of theories involve attempts to refute them.
Another reason why the field remained preparadigmatic as long as it did was the limited power and precision of the scientific tools that were available to investigate the tremen- dous complexity of human psychology. The power of sci- entific tools (e.g., telescopes and microscopes) is well known to constrain the scope of the findings that are pos- sible in the natural sciences. The development of practical functional magnetic resonance imaging (MRI) and genomic sequencing machines in the 1990s made it clear that prog- ress in the neuro- and behavioral sciences was also highly dependent on the power and precision of scientific tools.
Another reason why the behavioral sciences remained preparadigmatic as long as they did was the sheer complexity involved. Scientists now routinely refer to the human mind and brain as the most complex system known to exist in the universe. In just a three-pound organ are 86 billion highly connected neurons, each with an average of a thousand or more dendritic connections (Azevedo et al., 2009). Together they create feedback mechanisms across the biological, psycholog- ical, and sociocultural levels that result in structures and func- tions that also continually change and evolve. The complexity involved in this system is truly extraordinary compared with any other phenomenon known to exist, and uncovering and explaining this tremendous complexity will naturally take lon- ger than it does to describe and explain most other natural phenomena. This is ultimately the most important reason why psychology remained preparadigmatic longer than the physical and biological sciences.
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Emergence of the Behavioral Sciences as Paradigmatic Disciplines
Despite the truly extraordinary complexity of human be- havior, research has advanced dramatically in recent years, and a new scientific understanding of human psychology has emerged that is fundamentally different from what existed previously. There are many scientific advances that exemplify this new perspective, but two developments have been critical in establishing the behavioral sciences as par- adigmatic disciplines that are now consistent with the rest of the natural sciences. Without these developments, the be- havioral sciences likely would have not yet unified around a paradigmatic understanding of human psychology. One of these developments is theoretical, whereas the other is tech- nical. The theoretical development links psychology with the single greatest theoretical advance ever in biology, namely, evolutionary theory.
Importance of Evolutionary Theory
The importance of evolution in human development was recognized during the first century after Darwin (1859) published On the Origin of Species in 1859, but it was generally not thought to play a major role in higher level psychological characteristics because humans are so differ- ent from other species and culture plays such an important role in our mental life and behavior (Mameli, 2007). Evo- lution was viewed as responsible for basic innate mental abilities (e.g., sensation, perception, classical and operant conditioning, basic logical and probabilistic reasoning), but our more sophisticated mental characteristics were viewed as categorically different from these lower level capabilities. In recent decades, however, that view has changed.
Two major research achievements illustrate how evolu- tionary theory has become essential for understanding the origins, structure, and function of human psychology across all biopsychosocial levels of natural organization. At the biological level, the very complicated and peculiar structure of the human brain was poorly understood until Paul Ma- cLean (1967) applied an evolutionary perspective and iden- tified three basic structures: the “reptilian brain,” compris- ing the brain stem, cerebellum, and basal ganglia that are very similar to reptile brains; the “mammalian brain” that includes the limbic system, which is prominent in mammals that live in social groups; and the most recently evolved region of the mammalian brain, the cerebral cortex, which is especially highly developed in humans. Subsequent re- search found that MacLean’s original “triune brain” pro- posal was a simplification that needed substantial refine- ment (Streidter, 2005), but the highly complicated structure and function of the human brain remained largely a mystery before the application of the evolutionary perspective.
At the sociocultural level, prosocial behavior and al- truism were also largely a mystery until relatively re-
cently. It seemed that selfish and antisocial behavior would maximize the survival of individual members of a species, and yet humans and other social animals rou- tinely also demonstrate highly prosocial behavior and even altruism. In 1975, E. O. Wilson noted that this was the greatest theoretical problem in all of sociobiology at that time (Wilson, 1975). The solution to this problem involved changing the focus of evolutionary theory from the reproducing individual to the replicating gene— or- ganisms engage in behavior that promotes survival and replication of the gene, not necessarily the individual organism that carries the gene (Dawkins, 1976). This insight was critical for understanding the competing na- ture of individual and group selection that favors both selfishness (individual selection) and cooperation (group selection). These competing evolutionary pressures are also the source of many conflicted human emotions and cognitions (anger, competition, tribalism, curiosity, hu- mility, empathy, love) that are at the very core of human psychology (Buss, 2015; Dunbar & Barrett, 2007; Wil- son, 2014). Recent investigations into these types of questions are resulting in dramatic reconceptualizations of the major role of culture in the evolution of human social behavior (e.g., Morris, 2014; Pinker, 2011).
Many more examples could be presented that show how essential features of human nature are unintelligible without evolutionary theory (for reviews, see Buss, 2015; Dunbar & Barrett, 2007). At both the level of mecha- nisms (“proximate explanations of behavior”) and the level of “ultimate explanations of behavior,” or why life is designed in the manner it is (Tinbergen, 1963), human psychology cannot be understood from a scientific per- spective without evolutionary theory. This is true from the level of neuroanatomy and physiology (e.g., Ma- cLean, 1967), to infant attachment (e.g., Bowlby, 1969), to cognition and consciousness (e.g., Gazzaniga, 2011), to intimate and family relationships (e.g., Fisher, 2004), to interpersonal relations and social behavior (e.g., Pinker, 2011). The biologist Theodosius Dobzhansky (1973, p. 125) noted that “nothing in biology makes sense except in the light of evolution,” and it is now apparent that the same observation applies to human psychology as well. The behavioral sciences are now fundamentally linked at the theoretical level with the rest of the natural sciences in terms of both proximate and ultimate expla- nations (Buss, 2015). This is a historic development that, for the first time, unifies psychology around a paradig- matic theoretical perspective that is consistent with the rest of the natural sciences. This perspective may not yet be well integrated into PP education and practice, but it is fully accepted across the behavioral sciences generally as well as the biological and neurosciences (see Buss, 2015; Dunbar & Barrett, 2007).
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489UNIFIED CLINICAL SCIENCE
Importance of More Powerful Scientific Tools
A second critical development for establishing the neuro- and behavioral sciences as paradigmatic scientific disci- plines has been the invention and use of more powerful and precise scientific tools that have allowed experimental tests of hypotheses that had to remain speculations in the past (Wood et al., 2006). These include both conceptual tools (e.g., new statistical procedures) as well as technical tools (e.g., genetic sequencing machines). For example, the ge- netic sequencing of individuals’ genomes from around the world has found that all human beings now alive descended from the same parents (a common mother who lived about 200,000 years ago and a common father who lived about 142,000 years ago; Stringer, 2012). This and related re- search has overturned common misperceptions about the biological meaning of race (Omi, 2001).
Probably the most revolutionary technology that has pro- pelled recent advances in understanding the human mind and brain was the invention of imaging machines, particu- larly the development of practical functional MRI (fMRI) in the 1990s. Newer imaging machines such as diffusion ten- sor MRI and magnetoencephalography are further improv- ing both the spatial and temporal resolution of images of brain function. These new technologies are allowing in- creasingly precise observations of brain functioning at both micro and macro levels, and these are leading to dramatic advances in understanding a variety of psychological pro- cesses. For example, the brain has been found to be far more plastic than what was commonly believed just two decades ago (Davidson & Begley, 2012). Consciousness has also been found to arise from the interplay of a wide variety of neural structures, many that operate subconsciously, and the finding that the brain makes some decisions before the mind becomes consciously aware of them has raised challenging questions regarding the nature of responsibility and free will (e.g., Gazzaniga, 2011). When Freud and others proposed similar ideas in the past, the scientific tools required to rigorously test them were unavailable. That limitation has now been surpassed and knowledge of human psychology is surging ahead as a result.
Though research in many areas is still in its early stages, the tremendous complexity of human psychology is steadily being uncovered. Of course, it will take decades of addi- tional research to explain the precise nature and function of many psychological mechanisms and processes, and dis- agreements naturally exist regarding findings that have not yet been well replicated and tested, as is the case in any scientific discipline. It is also difficult to gain an integrated understanding of the existing research because the literature is fragmented as a result of the many specializations in- volved. Nonetheless, there is no major disagreement regard- ing the main findings that were mentioned earlier in this section with regard to the importance of evolutionary theory
and more powerful scientific tools. Despite all that remains to be discovered, the behavioral and neurosciences have advanced dramatically and a unified paradigmatic under- standing of human psychology has emerged that is consis- tent with theory and research across the natural sciences (APA Presidential Task Force, 2010). Psychology is no longer a preparadigmatic academic discipline, but has be- come one of the paradigmatic natural sciences.
Emergence of PP as a Unified Clinical Science
The recent transition of the behavioral sciences to a unified paradigmatic approach to understanding human psy- chology compels PP to reexamine its curriculum and clin- ical frameworks and guidelines so that any aspects that have become outmoded can be updated or replaced. Professional psychologists would all agree that PP is a science-based profession that needs to keep current with scientific ad- vances and update educational and clinical practices that are no longer supported by the best available scientific evi- dence.
Identifying changes that are needed at this point for PP to keep current with scientific advances will require extensive discussion. Central among the topics that need to be addressed is the theoretical basis for clinical prac- tice. The theoretical foundations underlying PP have been unclear throughout the history of the field, and there has been no consensus regarding the appropriate theoret- ical orientation or framework that should be applied to inform clinical practice. This problem now appears to have been effectively resolved, however, by the under- lying science having reached a unified paradigmatic un- derstanding of human psychology. To facilitate discus- sion on this and related topics, the following issues are suggested as implications of the current scientific under- standing of human psychology that PP could consider for possible integration into education and practice in the field.
A Single, Unified Theoretical Orientation
For the first time in the history of PP, the preparadigmatic array of conflicting theoretical orientations in the field can now be replaced with a unified paradigmatic scientific un- derstanding of human psychology. If PP embraces this position, it will precipitate the reexamination of several long-standing practices within the profession. For example, ever since clinical and counseling psychology became es- tablished as professions shortly after World War II, training programs have been given great latitude to decide their curriculum, because there was no consensus regarding a core curriculum or theoretical orientation that students en- tering the profession should master. This was specifically acknowledged at the 1949 Boulder Conference, where the
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conferees agreed that there should be a common core but also that there was not “one best way” (Raimy, 1950, p. 55), and they recommended that the issue be left to universities to decide. This perspective is still reflected in the current APA Commission on Accreditation (2013) Guidelines and Principles of Accreditation, which state that
the accreditation guidelines and principles are specifically intended to allow a program broad latitude in defining its philosophy or model of training and to determine its training principles, goals, objectives, designed outcomes, (i.e., its “mission”), and methods to be consistent with these. Stated differently, the Commission on Accreditation recognizes that there is no one “correct” philosophy, model, or method of doctoral training for PP practice; rather there are multiple valid ones. (p. 4)
The current scientific understanding of human psychol- ogy suggests a very different approach. From a paradig- matic scientific perspective, one does not select from an array of competing theoretical orientations or philosophies for understanding natural phenomena. Once falsifiable the- ories are sufficiently tested and verified using experimental research methods, then preparadigmatic orientations for un- derstanding those phenomena are replaced (e.g., once the germ theory of disease was demonstrated by Pasteur in the second half of the 19th century, miasma [“bad air”] theory and the Hippocratic humoral theory of disease were dis- carded). Replacing the preparadigmatic theoretical orienta- tions in PP with an integrated, scientific understanding of human behavior is critical for the field to be practiced as a clinical science that is unified around a scientific approach to understanding human psychology and behavioral health care.
The broad outlines of the current scientific understanding of human psychology are now evident. A very large body of replicated and well controlled research has examined a wide range of psychological processes from micro to macro lev- els, from epigenetics and neural plasticity to infant attach- ment, to the nature of consciousness and moral reasoning, to the impacts of social context and culture. These findings have also been integrated into falsifiable higher level theo- retical frameworks that are capturing the complexity of human development and behavior in an increasingly com- prehensive manner (e.g., Davidson & Begley, 2012; Fisher, 2004; Gazzaniga, 2011; Greene, 2013; Morris, 2014; Pinker, 2011; Ramachandran, 2011; Sroufe, Egeland, Carl- son, & Collins, 2005; Wilson, 2014). Though these frame- works cannot be discussed in detail here, it is critical to note that they all are based on the observation that human cog- nition, emotion, and behavior are dependent on underlying biological structures and processes that interact with psy- chological and behavioral factors, and that these in turn interact with social and cultural factors. Knowledge of the inextricably intertwined biopsychosocial domains of func-
tioning is simply necessary to the scientific understanding of human development and functioning (e.g., Engel, 1977; Melchert, 2015; Wilson, 2014).1 This is true from the level of neurons (e.g., neural plasticity; Davidson & Begley, 2012) to the level of the individual organism (e.g., the nature of consciousness; Gazzaniga, 2011) to the level of relationships (e.g., romantic love and parenting; Fisher, 2004) to the level of culture and society (e.g., the dramati- cally different ways that humans treat each other in modern society compared with previous eras; Pinker, 2011). It is also noteworthy how small a role the traditional theoretical orientations play in current scientific explanations of these various processes.
The current scientific understanding of human psychol- ogy is tremendously complex, but there is now overwhelm- ing evidence supporting this perspective. As a science- based profession, PP needs to incorporate this literature into PP education and practice. There is not one correct starting point or sequence for learning this literature. One could start with the sociocultural level of natural organization, partic- ularly because this level has had such a large impact on the recent evolution of biopsychosocial functioning and behav- ior. The psychological level is often covered relatively thoroughly in PP programs because of the field’s traditional emphasis on cognition, emotion, and behavior at the level of the individual. The biological level is often covered less well, particularly in terms of proximate and ultimate expla- nations of behavior.2 Figuring out how best to systemati- cally cover these three interacting levels in PP education will require significant exploration, but moving forward
1 George Engel introduced the “biopsychosocial model” in 1977 to counter what he viewed as the overemphasis on biology in medicine. His perspective has been highly influential throughout healthcare and is widely regarded as the appropriate framework through which to understand health and healthcare. It has also been pointed out that he misnamed his approach, however, because he did not propose a model in the scientific sense (i.e., that utilizes observations, rules, and scientific laws to explain a class of phenomena) but instead used the term in its colloquial sense (e.g., McLaren, 1998). Engel’s approach technically refers to a metatheoretical framework that points to the range of factors that need to be considered to understand theory and research in medicine (Melchert, 2015). It takes the same general approach as various integrative and eclectic approaches that have been introduced in PP and point to the range of factors that need to be considered to understand human psychology (e.g., Lazarus’s, 1976, BASIC-ID framework). But it does not refer to a falsifiable scientific model or theory that explains particular phenomena.
2 The APA Commission on Accreditation has required that accredited PP training programs address the biological, cognitive and affective, and social bases of behavior since the late 1970s. Programs were given signif- icant latitude in choosing how to cover those topics, however, because though it was obvious that biological, cognitive and affective, and social factors had major influences on behavior, an integrated biopsychosocial understanding that was consistent with the rest of the natural sciences (as described earlier) has only recently emerged. In addition, clinical case conceptualization and intervention typically have been based on one’s chosen theoretical orientation and not on an integrated understanding of the biopsychosocial basis of behavior. This led to many conflicting perspec- tives, several of which became highly controversial (e.g., regarding re- pressed memories of child sexual abuse).
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with implementing this approach could be relatively straightforward. For example, a future version of the APA Commission on Accreditation Guidelines and Principles of Accreditation might allow broad latitude in the educational methods used by training programs (e.g., online and tradi- tional courses), but require that the training principles, goals, and designed outcomes be oriented around the scien- tific understanding of human psychology—that is, there will be “one ‘correct’ philosophy of doctoral training for PP practice” (borrowing language from the current guidelines; APA Commission on Accreditation, 2013, p. 4). A future version of the APA Competency Benchmarks might like- wise include a standard that would read: “Assesses and evaluates cases and plans interventions based on the scien- tific understanding of human development, functioning, and behavior change.”
Reconciling the Unified Scientific Basis of Psychology With the Many Psychotherapies Available
For many professional psychologists, the most difficult aspect of the transition to a unified scientific approach to understanding behavioral health care may involve the loss of the traditional theoretical orientations as the basis for conceptualizing clinical cases. In the preparadigmatic era of PP, one’s personally adopted theoretical orientation played a major role in informing one’s understanding of the whole treatment process from the initial conceptualization of the nature and etiology of clients’ problems at assessment, to the treatment plan one recommended, the treatment one provided, and how one evaluated outcomes and effective- ness at the end of treatment. This is still usually considered the standard approach for learning the profession (e.g., as reflected in the APA Competency Benchmarks [Fouad et al., 2009] and the APPIC Application for Psychology In- ternship [APPIC, 2015]).
Replacing the traditional theoretical orientations with a unified scientific understanding of human psychology would not mean, however, that the traditional orientations play no role in behavioral health care. Though these orien- tations may not provide valid explanations of the mecha- nisms responsible for behavior change (e.g., even cognitive therapy, one of the most popular of the theoretical orienta- tions, is inadequate for that purpose; Kazdin, 2007), and they clearly do not provide comprehensive explanations of human psychology, they are still very useful. And they will continue to play an essential role in behavioral health care because they describe psychotherapies that have been em- pirically demonstrated to be safe and effective for achieving behavior change (e.g., APA, 2012). They would not be referred to as theoretical orientations because they do not refer to theories in the falsifiable, scientific sense of the term. They are appropriately referred to as psychotherapies,
however, that is, as systems of methods and processes that result in therapeutic improvements in large numbers of cases when applied appropriately. In other words, these therapies might still be found to be effective for ameliorat- ing distress and improving functioning even if their original theoretical formulations are no longer supported as proxi- mate or ultimate scientific explanations of human psychol- ogy. Most psychotherapies were developed before recent scientific research uncovered the mechanisms, functions, and origins of many psychological processes, and so it would not be surprising if their preparadigmatic theoretical underpinnings are not always supported by current scientific knowledge.
The scientific foundations of behavioral health care con- sequently rely on the now-well-established scientific litera- ture that explains human development and functioning as well as the extensive research that has demonstrated the safety and effectiveness of a variety of therapeutic interven- tions. Knowledge of both these topics is clearly far from complete, however, and particularly regarding the specific mechanisms and processes that result in psychiatric syn- dromes or that explain therapeutic improvements. To deal with this situation, PP has embraced the principles of evidence-based practice whereby practitioners consider the best available research evidence relevant to a case and integrate that with their clinical experience as well as cli- ents’ preferences, values, and culture (APA Presidential Task Force on Evidence-Based Practice, 2006).
It is important to note that medicine relies on the same evidence-based practice principles as PP because it operates in the same context of incomplete knowledge regarding health, dysfunction, and disease. Medical science has also made dra- matic progress, but there is still limited knowledge regarding the cause and cure of many medical conditions (e.g., idiopathic diseases such as Alzheimer’s, Parkinson’s, Type I diabetes, multiple sclerosis, many cancers, many seizures, and pain syndromes). As a result, ameliorating symptoms caused by these conditions often becomes the treatment goal. Even for diseases that are better understood, existing knowledge may be insufficient to indicate specific treatments. Take, for example, heart disease. Several medications are available to treat heart disease (e.g., anticoagulants, beta blockers, diuretics, statins) as well as a variety of surgeries (e.g., angioplasty, bypasses, stents) and implantable devices (e.g., pacemakers, defibrilla- tors). Behavioral changes are often prescribed as well (e.g., healthy diet, exercise, stress management, smoking and alco- hol use reduction). Predicting patients’ response to treatment can be very imprecise and consequently a stepped approach is often used where less intensive, invasive, and risky treatments are tried first (Bonow, Mann, Zipes, & Libby, 2012). Physi- cians should not base their evaluation and treatment recom- mendations on the dictates of a personally selected theoretical orientation but instead on the best available scientific knowl- edge, their prior experience, and patient values (Institute of
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Medicine, 2001). Despite incomplete knowledge regarding the etiology and treatment of many diseases, medicine nonetheless relies on a single, unified scientific approach to understand health and disease while employing a range of interventions that have been tested for safety and effectiveness. As clinical sciences based ultimately on the same incomplete body of scientific knowledge regarding human biopsychosocial func- tioning, medicine and PP both now use the same evidence- based approach to maximize the benefits and minimize the risks of health care intervention.
New Training Approaches and Resources
Transitioning to a paradigmatic scientific approach also raises questions about changes that may be needed in PP education to ensure it is consistent with current scientific knowledge and evidence-based practice principles. Many psy- chologists have considered aspects of these questions in detail, but broader discussions (e.g., within our professional organi- zations) may be needed to evaluate whether systematic changes are necessary to ensure that the field as a whole remains current in terms of education, practice, and research. A possible starting point for these discussions would be to revisit the question of the need for a core curriculum in the field and what it would look like if PP is approached as a unified clinical science (Benjamin, 2001). A useful way to begin this discus- sion would be to review the historical development of psychol- ogy from a preparadigmatic to a paradigmatic science that now has theoretical and empirical foundations that are consistent with the rest of the natural sciences. This could be followed by an examination of the implications of that transition for prac- ticing PP as a unified clinical science (e.g., along the lines suggested by the present discussion).
Discussions will also be needed regarding the appropriate breadth and depth of curricular coverage regarding the interacting biological, psychological, and sociocultural in- fluences on development and behavior. A variety of clinical topics would also need to be examined. For example, as a clinical science, it may be important to give more systematic attention to the epidemiology of behavioral health disorders, the interactions between behavioral and physical health and sociocultural factors, the most effective interventions for addressing different types of behavioral health problems, the prevention of behavioral health and other biopsychoso- cial problems, and the promotion of biopsychosocial health and functioning (Melchert, 2015). Discussions will likely also focus on the range of skills one should possess to conduct assessment, psychotherapy, and other behavioral health interventions in different types of general and spe- cialized practice settings. The range of skills in research design, measurement, and data analysis that are needed to evaluate research and carry out one’s clinical responsibili- ties also needs to be discussed. New training resources (e.g., textbooks, competency assessments) will need to be pre-
pared, new training models might be considered, and ac- creditation criteria and licensure standards may need to be updated, as will continuing education programming. These new educational resources and curricula will be especially important for training in integrated primary care (see the section titled Integrated Primary Care). A variety of stake- holder groups would likely be interested in examining as- pects of these questions that most directly pertain to them (e.g., graduate and internship training programs, health ser- vice provider groups, professional societies, accreditation and certification bodies), but it would also be important that these groups communicate with each other to ensure that important considerations are not missed.
The previous section noted the importance of evidence- based practice principles in health care generally. The im- portance of these principles in PP education specifically is exemplified by one of the most important documents in the field, the Diagnostic and Statistical Manual of Mental Dis- orders (DSM), a system that is based on limited scientific knowledge but still has significant clinical utility. The third edition of the DSM (American Psychiatric Association, 1980) was developed out of dissatisfaction with the low diagnostic reliability of the earlier editions. It relied on a descriptive, atheoretical approach that emphasized clinician interrater reliability while setting aside questions of etiol- ogy, and disorders were included based on voting by com- mittees. Many changes were incorporated into the latest (fifth) edition of the DSM (DSM–5; American Psychiatric Association, 2013), but it, too, relies on the same general approach as earlier editions. Well-known problems with this approach are excessive comorbidity, the proliferation of hundreds of putatively different pathological entities, and the lack of knowledge regarding the biology underlying the pathological syndromes (Cuthbert & Kozak, 2013). The science of psychopathology, however, has not yet advanced far enough to indicate an alternative approach. The National Institute of Mental Health was well aware of these problems when it launched the Research Domain Criteria project in 2008 to research relationships between dysfunctional be- havior and neurobiological systems. Because that and other research has not yet advanced sufficiently, the DSM–5 is widely regarded as the best available classification of men- tal disorders, despite its limited scientific foundations (Insel & Lieberman, 2013). Appreciating these issues is critical when PP is approached as a clinical science that relies on the principles of evidence-based practice.
More Clinical Perspective on Treatment Effectiveness
The voluminous literature that has accumulated in recent decades regarding the effectiveness of behavioral health care intervention has greatly strengthened the scientific foundations of PP. The general effectiveness of psychother-
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apy was unclear until Smith and Glass (1977) conducted meta-analyses that compellingly demonstrated that psycho- therapy was effective, even “remarkably efficacious” (Wampold, 2001, p. 71). Research further suggests that the effectiveness of psychotherapy often exceeds or is compa- rable with that of alternative psychopharmacological inter- ventions (APA, 2012). There are still vigorous debates regarding the biopsychosocial mechanisms and processes responsible for behavior change (e.g., the role of common factors vs. specific treatment effects; Wampold et al., 2010). This is not unexpected, however, given that psychological outcomes are multifactorially determined and the process by which individuals change is likely to be complicated as well. But there is no longer significant debate regarding the general effectiveness of psychotherapy.
One consequence of having established the general effec- tiveness of psychotherapy is likely to be greater attention on objectively evaluating the effectiveness of treatment in the individual case. Currently there is substantial emphasis on using empirically supported treatments as part of evidence- based practice, but additionally monitoring and demonstrat- ing the effectiveness of treatment using standardized out- come measures is likely to grow in emphasis as well. This practice is also important for identifying cases that include deterioration so that treatment can be adjusted to attempt a more beneficial outcome (Barlow, 2010; Lambert, 2010). Examples from medicine are again useful to illustrate the importance of this approach. For many medical conditions, standard practice includes the use of objective outcome measures, and it would be considered entirely inadequate to employ an empirically supported treatment without also systematically monitoring the effects of that treatment on an ongoing basis (e.g., routine blood pressure or blood sugar measurements to monitor the effectiveness of hypertension or diabetes treatment). Of course, many problems and ill- nesses are not reversed or cured (as is the case in behavioral health care as well). Nonetheless, treatments are typically monitored on an ongoing individual basis, modified as needed to maximize effectiveness and minimize risks, and continuing care for chronic conditions can extend for many years. As PP orients more clearly as a clinical science, further movement in this direction is likely as well.
Integrated Primary Care
Integrated primary care is currently being advocated in the United States and worldwide to improve the effective- ness and efficiency of health care delivery systems, for those with serious physical and mental illness as well as the population in general (e.g., Belar, 2012; Miller & Prewitt, 2012; World Health Organization, 2008). Patient-centered medical homes and other integrated primary care models are designed to take more holistic, biopsychosocial approaches to the assessment and treatment of physical and mental
illness and disease (Nielsen, Langner, Zema, Hacker, & Grundy, 2012).
There is also growing recognition within medicine of the importance of behavior in the etiology, consequences, and treatment of physical health problems. Indeed, it is esti- mated that fully 50% of morbidity and mortality in the United States is caused by behavior and lifestyle factors (Institute of Medicine, 2004). As a result, assessment and treatment in integrated primary care is biopsychosocial in orientation because of the clear interactions between med- ical, psychological, and sociocultural influences on health and functioning. Utilizing one or some combination of the traditional theoretical orientations to psychological practice can be very difficult or even impossible in these settings; instead, a science-based biopsychosocial approach is nec- essary (Health Service Psychology Education Collabora- tive, 2013; Melchert, 2015). If PP does not fill the need for behavioral health expertise in integrated primary care, other professions will.
Conclusions
Remarkable progress has been made in the scientific understanding of human psychology. Though many psycho- logical phenomena remain only poorly understood at this point, increasingly detailed explanations of numerous as- pects of human development and functioning are steadily accumulating. Psychology is now firmly grounded in ex- perimental findings and tests of falsifiable theories that are thoroughly consistent with the rest of the natural sciences. The speed at which this has occurred has also been remark- able. Indeed, many aspects of the current scientific under- standing of human psychology had not yet been discovered just a generation ago. Textbooks from that time typically relied on the traditional theoretical orientations to explain many features of personality, psychopathology, and psycho- therapy. Many textbooks in PP still take that approach. Textbooks in the future, however, will undoubtedly have completely different starting points for discussing these topics. They will likely note the historical importance of the traditional theoretical orientations, but will then proceed to discuss the increasingly well established proximate and ultimate scientific explanations of human behavior.
The evolution of psychology to a paradigmatic natural science discipline poses critical questions for PP as well. As a science-based profession, PP needs to identify outmoded frameworks and practices and replace them with approaches consistent with the best available scientific knowledge. Be- fore recent years, there essentially was no alternative but to rely on the various theoretical orientations for guiding clin- ical practice, because scientific knowledge regarding the tremendous complexity of human psychology was too lim- ited. Now that a paradigmatic scientific understanding has emerged, however, it might be considered irresponsible for
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PP not to systematically transition to the new scientific framework. Some might be inclined to propose still another theoretical orientation to attempt to capture the expansive and integrative biopsychosocial nature of human behavior, but that would not be a scientific approach. Science is cumulative, building on verified observations and experi- mental tests of falsifiable theories that explain how natural phenomena are structured and organized and why they function the way they do. New theoretical orientations in PP generally have not been designed to explain phenomena in this manner, but instead typically offer alternative explana- tions of phenomena based on the proponent’s experience and worldview. The regular introduction of new theoretical orientations was a main feature of the preparadigmatic era in psychology, but that era has come to an end.
Though difficult in some ways, transitioning to a unified science-based approach to education and practice in the field will be a very welcome development for many psy- chologists. This has always been, after all, the goal of the profession from the start. It would also mean that many of the perennial preparadigmatic conflicts between the theo- retical camps in the field can finally be left behind. More importantly, it would mean that PP would become a true clinical science guided by an integrated body of scientific knowledge that is consistent with the rest of the scientific disciplines and clinical professions. Moving ahead with a unified voice grounded firmly in science will allow PP to more effectively address people’s behavioral health and biopsychosocial needs. This is critical not just for the future of the profession but also for the health and well-being of the public who we serve.
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Received January 14, 2015 Revision received January 27, 2016
Accepted February 13, 2016 �
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496 MELCHERT
- Leaving Behind Our Preparadigmatic Past: Professional Psychology as a Unified Clinical Science
- Professional Psychology in the Preparadigmatic Era
- The Proliferation of Theoretical Orientations
- Reasons for the Preparadigmatic Proliferation of Theoretical Orientations
- Emergence of the Behavioral Sciences as Paradigmatic Disciplines
- Importance of Evolutionary Theory
- Importance of More Powerful Scientific Tools
- Emergence of PP as a Unified Clinical Science
- A Single, Unified Theoretical Orientation
- Reconciling the Unified Scientific Basis of Psychology With the Many Psychotherapies Available
- New Training Approaches and Resources
- More Clinical Perspective on Treatment Effectiveness
- Integrated Primary Care
- Conclusions
- References
Marketing and Distribution Channel Letter
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1 Unsatisfactory 0.00% |
2 Less than Satisfactory 65.00% |
3 Satisfactory 75.00% |
4 Good 85.00% |
5 Excellent 100.00% |
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90.0 %Content |
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20.0 %Description of the Product |
Description of the product is not present. |
Description of the product is present, but ideas are confused or incomplete. |
Description of the product is adequately presented. |
Description of the product is clearly presented with useful details. |
Description of the product is thoughtfully presented with rich and interesting details. |
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35.0 %Description of the Market Channels |
Description of the market channels is not present. |
Description of the market channels is present, but ideas are confused or incomplete. |
Description of the market channels is adequately presented. |
Description of the market channels is adequately presented. |
Description of the market channels product is thoughtfully presented with rich and interesting details. |
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35.0 %Description of the Distribution Channels |
Description of the distribution channels is not present. |
Description of the distribution channels is not present. |
Description of the distribution channels is not present. |
Description of the distribution channels is not present. |
Description of the distribution channels is thoughtfully presented with rich and interesting details. |
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10.0 %Mechanics and Formatting |
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10.0 %Mechanics of Writing (includes spelling, punctuation, grammar, language use) |
Surface errors are pervasive enough that they impede communication of meaning. Inappropriate word choice and/or sentence construction are used. |
Surface errors are pervasive enough that they impede communication of meaning. Inappropriate word choice and/or sentence construction are used. |
Some mechanical errors or typos are present, but are not overly distracting to the reader. Correct and varied sentence structure and audience-appropriate language are employed. |
Prose is largely free of mechanical errors, although a few may be present. The writer uses a variety of effective sentence structures and figures of speech. |
Prose is free of mechanical errors. Writer is clearly in command of standard, written, academic English. |
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100 %Total Weightage |
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Marketing and Distribution Channel Letter
This assignment challenges the student to think creatively.
The deliverable is a single-page letter addressed to a hypothetical website development company.
Place yourself in the role of a marketing executive in a hypothetical firm who is launching a new product that needs to be marketed.
Your firm has agreed to hire a professional website development company to market your product. The website developer needs the following information:
1. A brief description of the product
2. A description of the market and distribution channels
3. A description of the marketing activities
APA format is not required, but solid academic writing is expected.
This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
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