Innovation in psychotherapy part 1: innovation and progress

Update (April 2026): Since writing this, I've looked more carefully at the primary sources from Beck's early career, as well as Rachael Rosner's detailed historical account of Beck's intellectual development . The picture turns out to be messier (and more interesting) than Judith Beck's clean narrative suggests.

The 1961 dream study that supposedly refuted the psychoanalytic need-to-suffer hypothesis actually confirmed it : depressed patients reported significantly more "masochistic" dream content than nondepressed patients, in line with psychoanalytic expectations. The data didn't refute psychoanalysis so much as Beck gradually became disillusioned with it - partly through his research, but also through a series of painful institutional conflicts at Penn, including being twice rejected for membership in the American Psychoanalytic Association. His break was as much social and personal as it was scientific.

This doesn't undermine the broader point about CBT as a research-informed innovation. After all, it's based at least as much on Skinner's learning theory as Beck's cognitive approach. But it complicates the idea that Beck's was a clean case of data overthrowing theory. His story is better described as one of gradual, ambivalent departure - and notably, Rosner's research shows Beck privately continued to identify cognitive therapy as a neo-Freudian variant of ego psychology long after he was celebrated as the man who defeated Freud. The innovation-from-research narrative is real, but the details matter!

Thanks to Gary Brown, who pointed me to this.

A while ago, I started a Twitter survey on whether psychology is the “mother science” of psychotherapy. Roughly two-thirds agreed with the statement I thought would be uncontroversial. As an academic psychologist, I was strongly convinced about the “mother science” take. I still am. But I noticed that there are two opposing positions on this matter and that some nuance on this topic could be helpful.

Position 1: psychology is the core science of mental health . It provides essential theories, principles, and methods that underpin psychotherapy. While this position does not deny that some methods were not derived from psychology, it states that psychotherapy is likely to profit the most this way because they target well-understood core processes of psychopathology. Ultimately, psychotherapy is applied psychology.

Position 2: all major innovations come from outside of psychological research . Innovations stem from creative clinical practitioners, people with lived experience of mental health problems, or non-Western cultural traditions (like mindfulness, Mettā, Zekr, etc.). Often, the innovations are born out of necessity, for example when subgroups of patients do not respond to their treatment attempts. Formulated more sharply , psychology is ultimately an “auxiliary science” that empirically tests these creative innovations while contributing little to nothing new.

While position 1, of course, appeals to academic psychologists in the clinical fields, position 2 appeals a lot to practitioners, but also to those representing approaches that do not traditionally come from psychology. These include, first and foremost, the psychodynamic traditions, stemming from medicine. But even apart from that, it’s plausible. After all, like most arts and crafts, psychotherapy evolves as practices are tried out “live” and then either retained or discarded. Many old cathedrals look impressive but were not designed by academically educated architects on the drawing board but by trial and error . Clinicians who deal with the complexity of human psychopathology, often directly notice what works, what doesn’t work and how to modify their approaches.

Innovation and progress

I don’t think the two positions are incompatible. They probably both lack the distinction between innovation and progress. The fact that they appear irreconcilable is also due to the fact that they are characterized by different interest groups, all of which claim to define what “good psychotherapy” is.

While innovation refers to creating something new that was never done before, progress is the gradual improvement of practice. Progress implies not just novelty but an advancement toward more effective, reliable and generalizable therapeutic practices. Ideally, clinical innovations are tested, refined, and either integrated into the corpus of empirically validated therapeutic methods, or discarded.

Innovation and progress are not independent of each other. Innovation may provide the “raw material”, but without rigorous scientific consideration they remain a mixture of truths, half-truths and falsehoods . Progress without innovation, however, risks perpetuating the old patterns and can quickly lead to orthodoxy and inertia. While innovation often arises from practice, progress is often consistent with the gradual advancement of scientifically acquired knowledge.

But does this mean that innovations in psychotherapy must necessarily come from clinical practice? There are several examples here where it went the other way around. In fact, one of the most famous and still resonating innovations was cognitive behavioral therapy itself. Aaron T. Beck was a psychiatrist with psychoanalytic training. His research aimed to validate the psychoanalytic concept of depression, but, as summarized by his daughter :

He was surprised when his research appeared to refute the underlying tenets of psychoanalytic theory. Rather than confirm the psychoanalytic theory that depressed clients felt an innate need to suffer, Dr. Beck’s initial studies with depressed patients seemed to point to underlying negative beliefs associated with loss and failure. He soon began to understand that these underlying beliefs were consistent with the patients’ automatic thoughts, which could be accessed and collaboratively evaluated in session.

This is an example for the innovation of clinical practice by scientific discoveries. Beck was later to find out that his cognitive therapy was not only very effective, but also led to success much faster than the then dominant psychoanalysis. Later on, another innovation from research, metacognitive therapy, was developed. Adrian Wells took the results from his research on information processing and derived therapeutic techniques that helped many patients for whom Beck’s original cognitive approach was ineffective.

Details matter: the case of dialectical behavior therapy

The proponents of position 2 have their own examples. One of the most famous ones is dialectical behavior therapy (DBT), which was developed for the treatment of Borderline Personality Disorder. The development is often presented in this way: Marsha Linehan tried to treat parasuicidal patients with cognitive-behavioral therapy in the 1970s, but it was not effective for a certain group of patients - those who also suffered from what would be later known as Borderline Personality Disorder. This was followed by a lively experimentation with other strategies, informed by her personal history of mental health problems, from her experience with Zen Buddhism, as well as her clinical experience.

Although I won't deny that this contributed to the standard DBT protocol, this does not refute the statement at the beginning of the text. Linehan was a trained behavioral therapist. It would be absurd to state that her professional and scientific training in psychology had nothing to do with the development of DBT. So if someone claims that DBT was developed "from clinical experience", the appropriate response would be: "Clinical experience with what?". But let us have a look at what Linehan actually wrote about the innovation behind DBT. In an early book chapter, she introduces the newly developed strategies as follows:

The treatment strategies presented here are based on clinical experience with suicidal and parasuicidal patients as well as on the empirical data describing behavioral and environmental variables likely to interact with suicidal responses.

(Clarkin, J. F., Glazer, H. I., & Linehan, M. M. (Eds.). (1981). A Social-Behavioral Analysis of Suicide and Parasuicide: Implications for Clinical Assessment and Treatment. In Depression, behavioral and directive intervention strategies (p. 265). Garland STPM Press.)

Throughout the chapter, Linehan is very judicious in separating clinical experience and empirical evidence. Where the latter is lacking, the former is a valuable source of information. On the one hand, well-established techniques of behavior modification are grounded in learning theory and, thus, in research outside of clinical settings. This includes reattribution training and the handling of acute suicidal crises, which are based on empirical and theoretical work that can be traced back to other great minds in academic clinical psychology, like James N. Butcher .

On the other hand, she clearly states that the techniques that take place on the relationship level, such as extended contact with the therapist outside of the sessions (availability by telephone), stem from her clinical experience. This also applies to the general emphasis on the importance of creating a supportive therapeutic relationship or avoiding pejorative labels for suicidal and self-harming behavior. Now, the realization that the therapeutic relationship is important for the success of therapy was nothing new even in 1981, and one could at most argue that it is particularly relevant for this patient clientele. This is not enough to support the strong assertion that research-based progress plays no role in the innovation behind DBT and that psychological research only subsequently provides empirical support for the clinically and creatively derived techniques. Later on, Linehan introduced mindfulness- and acceptance-based approaches to DBT. Arguably, her own buddhist spirituality played a role here, but the vast majority of skills training contents were already described in her 1981 book chapter, where she traces them back to earlier empirical studies.

There may be therapeutic techniques that are more grounded in innovation and less grounded in research. Without much digging, I suspect that CBASP was actually developed very similarly to what is described in position 2. Once again, it will be up to research to ensure progress after innovation. As with so many innovative treatment concepts, it is not clear why they are effective at all. Conversely, proof of efficacy is not proof of mode of action. An innovative therapy method without empirical backup is incomplete. Whether CBASP is more effective than more established methods for treating chronic depression is still an open question and a matter of ongoing discussion (see this analysis , but also this response ).

In conclusion, it remains for me to say that these two positions will find their respective narratives. Even the examples I give can be presented differently to strengthen each position. However, a close reading of everything that has been written on the supposedly purely creativity-based innovations usually paints a differentiated picture and even the most creative innovations still require the scientific methods for validation.

It is quite clear that we need both the perspectives of researchers and their work to validate new concepts, but also the voices of the clinicians who conceive and apply them. How these voices could be productively networked so that the dialectic of innovation and progress is also transparently recorded will be presented in more detail in my next post.