The Age of Acronyms

Guest Post by Stephanie Foster

Stephanie Foster is a Registered Psychologist in Calgary, Alberta. She is in private practice and has provided short and long-term psychotherapy in a variety of treatment settings.

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On the first day of Christmas,

my true love sent to me

Another version of CBT

“The Twelve Days of Acronyms” parody song danced in my head as I encountered my third new acronym of the week. With alarming frequency, I happen upon so-called “new” approaches to psychotherapy.  Mental health professions are wild about acronyms. I haven’t seen this much excitement over letters since Sesame Street. Psychotherapy approaches are increasingly identified by two-to-five letter acronyms (ACT, AEDP, CBT, CPT, DBT, RO-DBT, EFT, EMDR, TF-CBT, IFS, SFT, SE… hang on, there are only 200 more). My colleagues commonly refer to modalities that I’ve never heard of. In an attempt to mask cluelessness, I usually nod and pretend to know what they are talking about. The moment the colleague is out of earshot, I investigate the latest acronym. This typically results in eye rolls, groans, and now songwriting. The number of acronyms seems to be growing exponentially. In fact, two new acronyms have been released since you started reading this article.

I didn’t always find acronyms so irksome, probably because there used to be fewer of them. I would describe my own training as a mix of humanistic principles and cognitive-behavioral therapy (CBT). The emphasis was on building the therapeutic relationship, coupled with the idea that the therapist could function as something of a skills trainer. I’m still on board with the former but have many qualms about the latter. In any event – and this is where I age myself – it seemed like a simpler time. Although the emphasis on techniques and acronyms was on the rise, we were generally steered towards broader categories of therapeutic intervention. The focus was on foundational principles and we were encouraged to find specific modalities that felt like a fit. At the time, there was one acronym to rule them all – CBT. Therapists can be rather notorious for jumping on the bandwagon and I was certainly no exception. I threw the CBT acronym around a lot. I would have gotten a tattoo but I don’t like needles.

The age of acronyms is upon the mental health world for many reasons, ranging from cultural to economic. This essay is not an exhaustive overview of the issue; rather, it is a personal reflection on my own experience with recent professional trends. For a good chunk of my career, I used acronyms in my advertising and professional conversations. I was following the crowd and had yet to develop the confidence to do anything different.  In recent years, I have ditched acronyms for the reasons I will share.

We Learn from People, Not Acronyms

The apprenticeship model defines the process by which we all become psychotherapists. A more senior practitioner acts in the role of supervisor to a more junior practitioner, with the aim of enhancing the clinical skill of the latter (Bernard & Goodyear, 2009). Clinical supervision is the “signature pedagogy” for the behavioral health disciplines (Bernard & Goodyear, 2019; Schulman, 2005). This is a very elegant way of saying that we’ve all been there. Any collegial discussion will yield a plethora of supervision stories, ranging from the terrific to the horrific. It has never been easy to be the master or the apprentice. But in an era of cost-cutting, the labor-intensive art of clinical supervision has been given the short shrift:

“I have noticed in recent years that agency sites emphasize and support supervision considerably less than they once did. Hospitals and counseling centers are currently under relentless pressure to “do more with less” – a maddeningly patronizing piece of self-serving magical thinking that invites clinicians to spin straw into gold. Whereas in a previous era most mentors would have had the time and institutional backing to help you become a better therapist, they may now have to supervise you almost on the run… Recent interns and trainees consistently tell me that they feel thrown into the deep end of the professional pool without a life jacket” (McWilliams, 2021, p. 187).

In the trenches of everyday clinical practice, many practitioners “…always feel lost and disoriented….” (Cozolino, 2022). Cozolino also notes: “The training has devolved to the point where students get out into practice and they don’t know how to swim, so they grab onto whatever weekend workshop serves as a life preserver.” Compared to stories like these, I count myself as rather fortunate. I had a supervisor who would hold court in his office while the trainees wandered in and out to ask questions. No acronym could hold a candle to even his off-hand remarks. I had supervisors flag my professional weaknesses long before I would have. I’ve had supervisors go to bat for me and supervisors tell me to rewrite lousy reports (that was the same supervisor, what a guy!). When I was inexperienced and nervous, there was always a lifeguard on duty. For every one thing I learned from a workshop or book, I learned a hundred from a person-to-person relationship. No one ever learned how to swim or how to become a therapist from a workbook. Just as people teach people how to swim, people teach people how to do psychotherapy.

This is not to say that I haven’t had periods of professional loneliness. Once I left the fold of training and licensure, the path to answers was no longer down the hall. There were times when I wasn’t sure who to ask, felt embarrassed to ask, or was frustrated by the answers I was getting. I found myself doing Internet searches and rummaging through worksheets, desperately searching for the next life preserver. It has occurred to me that the seminar and certification business – awash in acronyms – may be the self-help industry for psychotherapists:

“Anyone who comes up with a box or an off the shelf product – here’s what you need to do –  therapists will buy it! Why? Because they want to get better. And they know what when they go in the room, there is a lot of shit that happens that they didn’t figure out beforehand and they aren’t sure what to do about. The activity is fraught with ambiguity and that stuff is not going away” (Miller, 2020).

In psychotherapy, uncertainty is the only money-back guarantee. A practicing clinician cycles between knowing and not knowing, between confidence and crippling self-doubt. This cycle gets longer with time but never winds down. In my experience, what helps most today is exactly what helped in the beginning – people. I engage in clinical supervision and case consultation much as I did as a trainee. Supervision and consultation often return me to the working alliance fundamentals – the therapeutic bond, the therapeutic aims, and therapeutic methods (Bordin, 1994). These fundamentals are present in every therapy, regardless of what “brand” the therapist subscribes to. Indeed, many “stuck” therapy cases can be traced back to working alliance problems (Miller, Hubble, & Chow, 2020; Shedler, 2021). There are no quick fixes or acronyms for that, but rather a commitment to professional self-scrutiny that begins anew with every case. The devil is in the details and in psychotherapy most of all. A therapeutic brand for every human nook and cranny is the profession chasing its own tail. Rather than collecting tools for every situation, we should focus on fundamentals that work in most situations.

Rather than collecting tools for every situation, we should focus on fundamentals that work in most situations. As my clinical confidence has grown, my need to identify with a therapy brand has diminished. Effective clinicians do many of the same things.

As my clinical confidence has grown, my need to identify with a therapy brand has diminished. Effective clinicians do many of the same things (Jennings & Skovholt, 1999) and I’d prefer to follow their lead. My most cherished knowledge comes from experience with patients and colleagues. I joke that the suitable acronym might be PCT (Personal Communication Therapy). These ideas are not attributable to any modality but to thousands of individual interactions. My supervisors have often passed down the knowledge that was imparted to them.  Most of these emerging “brands” are a rehash of concepts that have been around for decades, if not a century. It seems disingenuous to pretend that I am doing anything new. In a recent social conversation, someone asked me what kind of therapy I practice and offered up some acronyms for my selection. I answered, “Plain old therapy.”

Acronyms Confuse and Mislead

I am bewildered by all the acronym therapies and I do this for a living. I can only imagine what this alphabet soup must look like to our patients. The jargon is probably useless to them, as patients have other priorities: “Most patients do not give a damn about theory. They simply want to get over their suffering” (Gabbard, 2005, p.333) We need to do in our public presentations what we do in the consulting room: Put ourselves in the patient’s shoes. The therapist’s doorstep is usually a patient’s last stop. It is common for patients to arrive demoralized or even on the heels of a crisis. Quite frankly, it is insensitive to ask patients to decipher the hieroglyphic world of our profession. I know that when I seek out a specialist for help, I am looking for a sense of care and competency. When confronted with jargon, I usually get the sense that the person is trying to impress, leaving me feeling rather unimpressed. I doubt that acronyms and insider lingo – often used for marketing purposes and as a signal to other professionals – do much for the patient looking for someone to talk to.

I say this as one who did a fair share of signaling themselves. For many years, I had acronyms on my public facing material. Why? Because it was what everyone else was doing. I was still trying things on for size and had yet to develop a comfortable professional identity. My development as a therapist was full of the characteristic growing pains. It took me years to find a therapeutic self that felt less like I was playing dress-up and more like a custom fit. Once I finally knew how I wanted to present my therapeutic approach, the jumble of letters seemed ill-fitting. I changed the focus from acronyms to highlighting the importance of the therapeutic relationship, listening, and collaborative goal setting. It was straightforward, clear, and jargon free. I believe this change came as a relief not only to me but to my patients.

This greater sense of ease was a long time coming. My steepest learning curve was discovering how my own anxieties and agendas were interfering with therapeutic work, an experience I have written about. At one time, I was better prepared to talk than to listen. I had scores of worksheets, interventions, and suggestions. I placed “productivity” over receptivity. Ironically, planning therapy in advance was ultimately less productive, as I was so preoccupied with the plan that I was often missing what was right in front of me. Over time, I realized that having a very specific approach in mind was a barrier to effective psychotherapy. I was trying to fit the patient to the approach when it must be the other way around.

In my experience, the presence of acronyms promoted a “pre-programmed” feel. It was like planning a conversation with someone I had never spoken to. The truth is that none of us knows how the first session – or any session – will ultimately go. Psychotherapy is an uncertain business and all the acronyms in the world won’t change that. When it came time to reconsider how I wanted to present myself to prospective patients, I thought it best to come from a place of humility, acknowledging the uniqueness of every psychotherapeutic encounter: “The therapist must strive to create a new therapy for each patient… Every course of therapy consists of small and large spontaneously generated responses or techniques that are impossible to program in advance” (Yalom, 2002, p. 35). Nowadays, I try to see the unknown for what it is – inevitable and as an opportunity. Rather than a paint-by-letters approach, I try to convey that therapeutic work is the process of figuring it out together.

 A Few Final Thoughts

I find solace in good theory, but I find a whole lot more in good people. Therapists, like patients, need relationships to grow. Psychotherapy is a lonely profession and clinicians can easily find themselves drifting into isolation.  The modern therapist may need to make active efforts to connect with like-minded colleagues and experienced consultants. In my own experience, this has been the best way to increase clinical confidence and drown out the siren song that accompanies every new fad. This doesn’t mean that I am dismissive of emerging trends but feel better able to approach them from a place of thoughtful consideration. I fear that many trends are adopted from a place of professional desperation.

I have also come to believe that acronyms distract from the core of psychotherapy. The therapy process centers around the patient/therapist relationship, while acronyms place the emphasis on techniques. Quite simply, a heavy focus on techniques may be a waste of time:

“The technique is, in general, the weakest contributor to outcome in psychological care… It’s the first thing that people reach for when they think they have a deficit in performance and it is what the field coughs up constantly” (Miller, 2023).

While therapists must have techniques, they are best when integrated into a coherent therapeutic self and the working alliance: “Professional training that addresses only or primarily the techniques of psychotherapy quickly becomes arid, disembodied, and decontextualized” (Norcross, 2005, p. 840). I think many clinicians, including myself, have found themselves dispensing interventions that came from outside the consulting room, as opposed to generating them from inside the relationship. Presupposing the nature of the treatment can cause therapists to miss important patient cues, increasing the likelihood of treatment failure (Gnaulati, 2022). Arriving to psychotherapy with prefabricated techniques is like trying to decorate a house that you’ve never seen the inside of.

In the words of Harry Stack Sullivan, we are all more human than otherwise. If these acronyms have me rolling my eyes, it is reasonable to think that patients might experience similar irritation. Patients have everything to teach us about how to communicate with them and there is no indication that they ordered the alphabet soup: “When you survey clients, they overwhelmingly want a therapist who is a good listener and who has a warm personality, not someone skilled in the latest techniques” (Gnaulati, 2018). Little by little and letter by letter, acronyms obscure the essence of psychotherapy. In the consulting room, the whole is greater than the sum of the parts: “Despite impressive attempts to experimentally render individual practitioners as controlled variables, it is simply not possible to mask the person and the relational contribution of the therapist” (Norcross, 2005, p. 840). The effort to slice and dice every aspect of therapeutic intervention is akin to stripping a car for parts – and in the end, therapists might not be able to drive anywhere. On the winding road of therapy, the driver matters more than the make and model of the car. We need to teach therapists how to drive before selling them all the added features. If the profession can reorient itself towards the foundational principles that have always served us well, then perhaps we can put the brakes on all of these acronyms. IMHO. FWIW.

*To maintain confidentiality, all patient references are fictionalized composites.

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See also:

The Remaking of a Therapist

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References

• Bernard, J. M., & Goodyear, R. K. (2009). Fundamentals of clinical supervision (4th ed.). Columbus: Merrill

• Bernard, J. M., & Goodyear, R. K. (2019). Fundamentals of clinical supervision (6th ed.). Pearson.

• Bordin, E. S. (1994). Theory and research on the therapeutic working alliance: New directions. In A. O. Horvath & L. S. Greenberg (Eds.), The working alliance: Theory, research, and practice (pp. 13–37). John Wiley & Sons.

• Lou Cozolino talks about educating psychotherapists (Louis Cozolino). Hosts: Matthew Dahlitz and Richard Hill. The Science of Psychotherapy Podcast. January 13, 2022. Quotes at 6 mins, 53 seconds and 6 mins, 20 seconds.

• Evans III, F. B. (1996). Harry Stack Sullivan: Interpersonal theory and psychotherapy. New York: Routledge.

• Gabbard, G. O. (2005). How Not to Teach Psychotherapy. Academic Psychiatry, 29(4), 332–338. https://doi.org/10.1176/appi.ap.29.4.332

• Gnaulati, E. (2018, February 15). Is "Evidence-Based" Off Base? Psychology Today. https://www.psychologytoday.com/us/blog/in-therapy/201802/is-evidence-based-base

• Gnaulati, E. (2022). Overlooked ethical problems associated with the research and practice of evidence-based treatments. Journal of Humanistic Psychology, 62(5), 653–668. https://doi.org/10.1177/0022167818800219

• Jennings, L., & Skovholt, T. M. (1999). The cognitive, emotional, and relational characteristics of master therapists. Journal of Counseling Psychology, 46(1), 3–11. https://doi.org/10.1037/0022-0167.46.1.3

• McWilliams, N. (2021). Psychoanalytic Supervision. The Guilford Press.

• Miller, S. D., Hubble, M. A., & Chow, D. (2020). Better Results: Using Deliberate Practice to Improve Therapeutic Effectiveness. American Psychological Association. http://www.jstor.org/stable/j.ctv1chrrmr

• Getting Better Results from Your Patients as a Psychotherapist – Episode 077 (Scott Miller and David Chow). Host: David Puder. Psychiatry and Psychotherapy Podcast. March 19, 2020. https://www.psychiatrypodcast.com/psychiatry-psychotherapy-podcast/2020/3/19/getting-better-results-from-your-patients-as-a-psychotherapist. Quote begins at 59:10.

• Using Deliberate Practice to Improve Psychotherapy Results with Scott Miller – Episode 186 (Scott Miller). Host: David Puder. Psychiatry and Psychotherapy Podcast. July 7, 2023.  https://www.psychiatrypodcast.com/psychiatry-psychotherapy-podcast/186-using-deliberate-practice-to-improve-psychotherapy-results-with-dr-scott-miller. Quote begins at 1 hour 12 min.

• Norcross, J. C. (2005). The Psychotherapist's Own Psychotherapy: Educating and Developing Psychologists. American Psychologist, 60(8), 840–850. https://doi.org/10.1037/0003-066X.60.8.840

• Shedler, S. [@jonathanshedler]. (2021, June 11). There are 3 necessary elements of a working alliance in therapy. Most clinicians miss #2 or #3[Tweet]. Twitter/X.

• https://twitter.com/JonathanShedler/status/1403231671877464074

• Shulman, L. S. (2005a, February 6-8). The signature pedagogies of the professions of law, medicine, engineering, and the clergy: potential lessons for the education of teachers. Presentation at the Math Science Partnerships (MSP) Workshop: Teacher education for effective teaching and learning. Retrieved from www.taylorprograms.com/images/shulman_signature_pedagogies.PDF

• Yalom, I. D. (2002). The gift of therapy: An open letter to a new generation of therapists and their patients. HarperCollins Publishers.