The Gallagher Clinical Dogma Test

Most therapists have been trained in a particular approach to treatment for anxiety disorders: CBT, ERP, ACT, third-wave, psychoanalysis, or whatever. And if there is reasonable evidence for what you are doing, that’s great. 

But are you TOO wedded to your way of doing things, to the point where it may actually be harming your clients? 

Here is a simple test: Let’s say that you tried your usual treatment approach with your client. They gave it a fair shot. The client reported that it didn’t help or made things worse. Check the boxes below if you did any of the following:

⎕ Implied they were doing your approach wrong, or haven’t practiced it enough.

⎕ Stated that they weren’t working hard enough at it.

⎕ Tried to “motivate” them to recommit to your form of treatment.

⎕ Described them – in your notes, or worse, to them – as a “treatment failure.”

⎕ Did not suggest – or refused to try – any approaches besides yours.

⎕ Used the terms “evidence based” or “gold standard” at any time AFTER the client disclosed your approach wasn’t helping.

⎕ Said something to the effect of “Almost all my clients succeed with my approach, but if you are an exception, I can refer you out.”

⎕ Suggested that they should come back when they are ready to work on their problems.

Scoring: Give yourself one point for every box you check. If your score is anywhere between 1 and 8, you are putting your dogma ahead of your clients' interests, and the problem is you.

So what is the theoretical basis behind this highly accurate clinical assessment? Simple. In my nearly 70 years on this planet, and my own lived experience with anxiety disorders, I have been told every single one of these things myself in treatment. And I have extensive outcomes data as well: every single one of them turned out to be wrong, and a different approach eventually worked much better for me.

Moreover, this assessment has been validated across every major treatment strategy of the last half century: I have heard these things from people practicing psychoanalysis, CBT, ERP, third-wave approaches and even finding my inner child (seriously). 

Finally, this has been cross-validated by years of seeing clients myself as a psychotherapist, as well as my connections with other therapists dealing with their own anxiety disorders. These results are consistent as well: collectively we are all TIRED of having treatment providers blame us for the failures of their approaches – and worse, having the burden always be on US to navigate among clinicians who see just one way to do things, as we seek proper treatment.

Joking aside, evidence-based treatment strategies do matter. You just can’t use them as a blunt instrument for everyone, while ignoring how well they actually work for each client. 

I actually keep up with the literature on anxiety treatment, and actual research to date on it is still nuanced, incomplete, and continuing to evolve. And it feels clear to me that, ever since the days of Freud, the single biggest cause of treatment failure in our profession lies not in our methods, but our tribalism about these methods. And the EBT specialist who presses on when their approach isn't helping is just as guilty as, say, the Gestalt psychoanalyst who won't mention evidence-based approaches.

Personally, I am a hardcore cognitive-behavioral therapist who practices ERP, ACT, IBT, mindfulness, and other evidence-based strategies. I am also an engineer by training who believes in science. But I never shamed clients, gave up on them when something wasn’t working (although I did sometimes collaboratively refer them to other experts), or put my training ahead of the person in front of me – and perhaps more important, never stopped learning.

So, did you discover that your own dogma may be getting in the way of your effectiveness as a therapist? There is a proven approach for dealing with this, popularized a few years ago by Bob Newhart’s fictional psychologist Dr. Switzer: Stop it!