In thinking about career goals as a teenager, I originally went to a magnet/ specialized high school in New York City—Brooklyn Tech. This school is a STEM-based training ground for budding engineers and scientists that housed a population of about 6000 boys at that time (since I graduated, girls were admitted). Engineering, particularly the science and mathematics behind it, appealed to me at that time. However, because I attended high school during the late sixties, I was also very absorbed in social justice, being one of those kids who had long hair and participated in multiple protest marches against the Vietnam war. Living about 1.5 h from high school, I needed to take one bus and two subway trains to get back and forth from my home in Queens to Brooklyn. During the time on public transportation, rather than focusing on unfinished homework assignments, I found myself staring at the various bus and subway passengers (remember this is New York) and making up stories about their jobs, relationships, problems, and general life circumstances. This was fun! It was also very engaging when discussing such stories with like-minded student peers.

Being very curious, I started to read psychology books, as well as magazines (including Psychology Today) to obtain a better (academic) grasp of people. This may be a worn-out adage, but I wanted to know “what makes people tick!” This experience, coupled with my concern for social justice, led me to apply to Stony Brook University (then known as a liberal-leaning institution) with the hope of eventually becoming a social psychologist. My goal was to eventually help develop policies, based on psychological principles, which could “help people and make a difference.” However, learning more about academic psychology, in tandem with my extensive volunteer work at local psychiatric hospitals, led to a change of direction— I wanted to become a clinical psychologist, one who could directly impact people’s lives for the better. In college, I was one of those lucky students who had a specific goal to work towards. Fortunately, the psychology department at Stony Brook thought I was sufficiently worthy to continue my studies there and I was granted admission to their clinical PhD program.

Wow!

My graduate training at Stony Brook had two major personal influences— it reinforced my interest in applying a scientific overlay to psychological phenomena and it introduced me to a social learning perspective, one that emphasizes psychotherapy approaches that reside under a cognitive-behavioral umbrella. Since this approach is adamant about being scientifically supported, it is a good segue to highlight next my strong adherence to a scientific perspective of psychotherapy.

I consider myself a scientist and view the world via a scientific lens. I believe that what we owe our patients are the best treatments and information possible based on empirical evidence. This belief has led me to adopt the view that a sizable part of my activities as a psychologist should be to participate in multiple ways in the profession within this context. For example, I have conducted multiple research studies, received grants, reviewed grant applications, and peer reviewed scores of research-oriented journal articles. I previously served as the Editor of the Journal of Consulting and Clinical Psychology and am currently the Editor-in-Chief of Clinical Psychology: Science and Practice. I taught research methods courses to doctoral and masters psychology students for decades and was previously a member of APA’s Board of Scientific Affairs. This is not to suggest that I am anything more special than my psychologist colleagues— rather, my commitment is to try as best as possible, to “walk the walk” (although being human makes this a significant challenge at times). Therefore, as a practicing psychotherapist, I attempt to influence all that I do in that role by my scientist background.

It is important to note here that I believe science to be a process and not a collection of stagnant “facts.” Both the results of scientific studies as well as the methods themselves used to engender these results are always evolving and not static. More importantly, I believe that a “true” scientist fights against omnipresent biases that can occur as a function of one’s professional discipline, theoretical orientation, or narrow thinking. For example, unfortunately, the proverbial debate between “nature versus nature” in some mental health arenas continues to exist. Note that a phrase lay people often use to underscore the significance of certain human phenomenon is the statement “it is in our DNA.” This affirmation continues to perpetuate the overly simplistic explanation of the role of genetics in directing human behavior. Such a viewpoint severely limits the progress of our understanding of human behavior, a discussion I frequently engage in with patients.

Relevant to psychotherapy, the above perspective underscores the belief that strict adherence to a particular theoretical orientation or treatment modality can limit our ability at times to place ourselves outside of a conceptual silo. Although I characterize myself as someone who generally practices within a broad-based cognitive and behavioral umbrella, I often find myself at times having the need to remind others who practice similarly (especially graduate students in training), that scientific evidence supporting the efficacy of non-CBT-based interventions does in fact exist. For example, a meta-analytic overview regarding the comparative efficacy of psychological treatments for depression identified CBT as the most examined type of intervention, but “not necessarily more effective than other therapies” (Cuijpers et al., 2025, p. 297). Science is important, but an overreliance and narrow view of a particular set of findings can stifle progress and creativity. For instance, a meta-meta-analysis (meta-analysis of a group of meta-analyses) found a significant association between a strong researcher allegiance to a particular therapy approach and poorer treatment outcome among RCTs that compared two or more forms of psychotherapy (Munder et al., 2013). This suggests that bias can sometimes even affect the way we engage in scientific endeavors (note that I use the pronoun “we” to include myself among this cohort due to my being human which makes me vulnerable to heuristic thinking at times). Ultimately, I believe it is important to try to always keep an open mind when acting as a professional consumer of scientific data.

As noted previously, I refer to myself as a broad-based cognitive and behavioral therapist. This is the second major influence that my graduate training at Stony Brook had on me. To a large degree, this orientation advocates adopting a strong empirical approach to both assessment and treatment (Nezu & Nezu, 2016). As such, given my earlier interest in science and engineering, it is natural that this would be the approach that I adopt. However, many other therapies and theoretical orientations are empirically based. But for me, what is especially important is the embracing by this framework of a biopsychosocial model of human cognition, affect, and behavior. Such an approach has a very wide bandwidth of potential etiological and maintaining factors that help to explain human phenomenon, as well as implicating strategies that can lead to important behavior change. This approach strongly suggests that models of both “normal” and “abnormal” behavior should include a variety of biological (including genetic, physiological, and neurological factors), psychological (including behavioral, cognitive, and affective factors), and social (including cultural, environmental, and interpersonal factors) components and how they interact with each other. I personally believe that, except in very rare cases, because of omnipresent individual differences, which factor or set of factors predominant in “causing” psychological difficulties vary across people, rather than one variable singularly being responsible for explaining why someone experiences certain life problems.

Adopting a biopsychosocial framework further opens one ‘s vista to appreciating the myriads of potential influences on the experience of distress beyond individual psychological processes (which tend to be the “meat and potatoes” of many clinical psychological theories). This is why I became interested in public health. For example, one of my areas of research and clinical practice earlier in my career in clinical health psychology involved treating obesity (e.g., Perri et al., 1992). In my practice, it was always important for me to help patients appreciate the (sometimes intense) influence of commercial entities constantly tempting one to eat higher caloric and fat content foods. Not understanding the immense social pressure to act against one’s goals to lose weight misses the big picture. How best to cope with this pressure became an important issue in successful treatment.

Although I did read multiple books by Sigmund Freud in high school, as already noted, I was heavily influenced by a cognitive and behavioral approach at Stony Brook. However, going to graduate school in the early 1970’s, a “behavioral” approach, which was predominantly based on models of conditioning (both respondent and operant), was beginning to change. At that time, cognitive and constructivist theorists, such as Fred Kanfer, Albert Bandura, Michael Mahoney, Albert Ellis, Tim Beck, and Donald Meichenbaum began to advocate the importance of cognitive factors in understanding psychopathology and human behavior in general.

As part of this movement, my mentor at Stony Brook, Tom D’Zurilla, along with Marv Goldfried, began to focus on the construct of cognitive problem solving as being especially important in understanding “positive” mental health. They developed a prescriptive model of training to help people become more effective problem solvers as a means of better managing the exigencies of stressful problems in living and improving their overall well-being (D’Zurilla & Goldfried, 1971). As a graduate student, I helped conduct studies that evaluated various underlying tenets of the model (e.g., Nezu & D’Zurilla, 1981) and later evaluated the clinical utility and efficacy of “problem-solving therapy (PST)” as a treatment for clinical depression among adults (Nezu, 1986).

For those who may be unfamiliar with PST, the conceptual underpinnings proffers that what is generally thought of as psychopathology and behavioral difficulties is often a function of frequent unsuccessful coping with life stressors. Thus, training people to become more effective life problem solvers serves to attenuate extant mental health difficulties. In general, the major goal of PST is to promote a sense of optimism and positive self-efficacy and the effective implementation of specific coping behaviors, including adaptive emotional regulation and planful problem solving and decision making.

Phil Kendall once introduced me as both a “pioneer and a settler” of PST as I was intimately involved with Tom D’Zurilla during the early stages of the development of this type of therapy, as well as devoting a significant part of the rest of my career (to this day) in further refining and revising the treatment model, as well as continuing to evaluate its efficacy as a clinical intervention for numerous behavioral and medical populations. As an example of my commitment to a biopsychosocial model, Chris Nezu (my colleague, wife, and frequent professional collaborator and the major reason for any success I enjoy) and I more recently revised PST to incorporate research and theory from affective neuroscience, especially focusing on various brain-behavior interactions that are involved in emotion reactivity in response to stressful events, much of which are non-conscious and often learned on a pre-verbal level. We termed this revision Emotion-Centered Problem-Solving Therapy (Nezu & Nezu, 2019). This approach is geared to help patients learn to better recognize the source of their distress, to improve their ability to regulate and manage their negative emotional reactions to stressful circumstances, to enhance their cognitive problem-solving skills, and to foster their resilience when faced with the desire to “give up.”

Parenthetically, I am often asked if this intervention is the sole or predominant treatment I apply in my role as a therapist regardless of patients’ presenting problems or goals. The answer is emphatically “no.” Not because I think PST-based approaches are not that effective (in fact, it is generally considered by multiple professional organizations to be a transdiagnostic, evidenced-based intervention for multiple psychological problems across the life span), but because I believe that there is no such treatment protocol that is 100% effective, 100% of the time, for 100% of people. That is not a profound statement—but an acknowledgement that more frequently than not, individual differences outweigh similarities among humans. Each of these individual characteristics should be considered. As the saying goes—“it’s important to meet people where they are!” Within this context, multiple other evidenced-based interventions may be more appropriate for a given patient.

In keeping with the above philosophy, I am a huge advocate for using a case formulation approach when working with patients. Case formulation underscores the need to (a) conduct a comprehensive assessment, (b) attempt to “really get to know a patient and learn their story,” (c) use disconfirming as much as confirming questions to combat ubiquitous heuristics, (d) not assume that “what you see is what you get,” especially in terms of physical characteristics of a prospective patient (e.g., clothes, skin color, weight, etc.), and (e) respect the diversity among people (Nezu et al., 2007). As Tarrier and Johnson (2015) suggest, case formulation is “the translation of theory into therapy” (p. 4). In other words, this approach draws upon scientific literature to apply it on an individual basis, instead of conducting a treatment based solely on a patient’s diagnosis or (seeming) presenting problem via a treatment manual. It suggests to therapists that they need to develop a set of testable hypotheses about the “why and how” a particular person is experiencing a set of undesirable difficulties to best determine “what to do” to help him or her overcome them. By virtue of its sensitivity to focusing on “the person in front of the therapist,” as compared to the temptation, engendered by heuristics, to react to a stereotype based on a diagnosis, a case formulation approach can also foster the therapeutic alliance (C. Nezu et al., 2015). With specific reference to a cognitive and behavioral orientation, Tarrier and Johnson further note:

The clinician should create explanatory structures or heuristics for understanding the client’s problems but proceed with caution not to muster evidence selectively only in their support but to examine critically why their heuristic and hypotheses may be incorrect and can be shown to be so. It is this refinement of testable hypotheses upon which treatment strategies are based that prevent cognitive behavior therapy from becoming a mere cookbook of clinical techniques (p. 4).

This later statement is especially important to consider as I believe some novice therapists often want to follow (at times rigidly) an evidenced-supported treatment manual for a given diagnosis without truly understanding how best to apply such a treatment manual to a given person (C. Nezu & Martell, 2020). According to the American Psychological Association, best practices in conducting psychotherapy needs to include a meaningful integration of research and clinical experience while considering a patient’s characteristics, culture, and preferences (APA Presidential Task Force on Evidenced-Based Practice, 2006). The efficacy of one’s clinical experience, in my view, can be greatly enhanced by using a case formulation approach. It can increase flexibility, adaptability, and improved patient outcome (Nezu et al., 2007).

I previously underscored the notion of respecting the importance of individual differences among people (Nezu, 2010):

It is my belief that any difference, whether one is born with six fingers, is especially tall or short, overweight or underweight, is physically attractive, athletic, a twin, gay, or has a great singing voice, can potentially serve as an influential psychosocial factor on one’s cognitive, emotional, and behavioral development. Growing up with a wonderful voice is likely to be a positive influence (although not necessarily), but having six fingers will probably lead to various negative encounters (p. 170).

With direct relevance for psychotherapy practice, I especially like to use the template proffered by Pamela Hays (2016) as a means of capturing the diversity of individual differences. The acronym she developed, ADDRESSING, represents the following categories to consider when attempting to best understand and appreciate the “full picture” of a given patient: A (age), D (developmental disability), D (disability acquired later in life), R (religious/spiritual orientation), E (ethnicity), S (socioeconomic status), S (sexual orientation), I (indigenous heritage), N (national origin), and G (gender). More recently, she described how this framework can help therapists better understand the intersectionality among these characteristics (Hays, 2024).

However, I continue to be surprised, when year after year, I find that many graduate students whom I teach or supervise rarely ask patients about their religious or spiritual beliefs or how age impacts their lives. When student supervisees are directed to inquire about these beliefs, they are often surprised regarding the extent to which such patient viewpoints influence mental and behavioral health. Strong respect for ethnic and sexual orientation diversifications tends to be a common attribute of trainees these days but encouraging them to use the above template can further ensure that they address multiple patient characteristics, especially if voiced as being important by patients themselves.

An important aspect of respect for diversity involves the acknowledgment that certain “different” groups of people have been marginalized socially, economically, and judicially as a function of their skin color, sex, gender orientation, or cultural background. As a person of color myself (i.e., Japanese American), I am acutely aware of the significance of this perspective. Once again, adhering to a biopsychosocial framework encourages me to focus on the influence of various social, cultural, and interpersonal factors that impinge on patients’ health. In addition, research focusing on the “bio” component of this model has further documented the negative impacts of racism and discrimination on brain health (Grasser & Jovanovic, 2022; Harnett et al., 2024).

I often tell my supervisees that I believe that if, via a positive therapeutic relationship, a patient and I come to be “on the same page,” treatment outcome is facilitated. Of course, all therapists respect the significance of a positive therapeutic alliance, so I will not belabor that point. The issue here concerns the importance of educating patients about one’s case formulation and how that case conceptualization leads to treatment recommendations. I know that when I seek help from a medical or dental professional, I have a strong desire to learn why certain symptoms that I am currently experiencing came to exist, and especially how that informs the treatment process. When that occurs, I feel that I am being treated respectfully, in addition to having the option of engaging in mutual decision making. I have found that the more my patients understand the “why” behind what I recommend and ultimately implement, the greater the likelihood that the outcome is positive. Getting back to my need to be scientifically minded, research has shown that psychoeducation interventions by themselves can reduce symptoms (e.g., Donker et al., 2009). Note that I am not recommending a basic psychoeducation protocol as a major treatment regimen; rather, it is important to explain to patients the why, what, and how of the therapy. Moreover, it is the ethical thing to do, which is a good segue to my next tenet—ethics.

I would like to believe that I was always an ethical therapist, but since I began teaching the doctoral course in ethics over a decade ago, my view of the relevance of ethical issues as applied to everything I do as a therapist has increased. For example, as noted above, I believe that psychoeducation is an important aspect of therapy. From an ethical standpoint, however, conveying relevant information to patients should be viewed further within the context of informed consent. In addition, I previously suggested that ethical considerations should be a routine and vital component of evidence-based practice in psychology (Nezu, 2020). Given the impact of realistic limitations of the empirical literature, the ubiquity of human errors due to common heuristics, and the paucity of research devoted to the influence of various individual patient characteristics (e.g., co-morbidity status; gender, sexual orientation, and ethnic differences; spiritual/religious variability), diagnosis, assessment, and treatment decisions should be made within the context of ethical considerations. In that article, I argued that the following areas of a therapist’s activities are particularly important to focus on from an ethics perspective: competence regarding the ability to make accurate problem identification and develop a meaningful case formulation, multicultural competence, clinical decision-making competence, the ability to determine when treatment is harmful or non-beneficial, competence in establishing a constructive therapeutic alliance, competence in making referrals and/or terminating when appropriate, managing conflicts of interest, and engaging in continuous informed consent (and not just at the beginning of treatment). Bottom line, this suggests that we all should engage in continuous self-reflection about what we do as a therapist. Remember that I mentioned at the beginning of this paper that I was grateful for the opportunity to author this article as it provides me with yet another major occasion to do just that— think about what I am doing as I therapist.

Lastly, I believe it is particularly important to listen to patients, ask about their preferences, and request feedback about their experience of psychotherapy (Swift et al., 2021). According to Timulak and Keogh (2017):

Research suggests that therapist willingness to seek client perspectives, openness to hear what clients have to say, nondefensiveness in the face of negative feedback, and ability to modulate actions accordingly are all likely to contribute to stronger relationships with clients and stronger collaboration, correspondingly contributing to stronger therapeutic outcomes (p. 1556).

I frequently tell my graduate students that just because I have several letters after my name, I do not have the right to claim that I am omniscient. On one hand, 40 + years as a psychologist does speak to my competence as an effective therapist, but it should not translate into one who is “all knowing.” As noted previously, engaging in a meaningful dialogue with those medical and dental professionals with whom I am seeking care makes me feel respected and “listened to.” Why should I not afford the same experience for my patients?

In addition, such feedback sessions for me are meaningful learning experiences and serve to enhance my own ability to be an effective therapist. As such, in that context, I wish to thank all those patients over the years for whom I provided therapy for their contributions to my growth as a clinician. In the same spirit, I wish to thank various colleagues who were kind enough to be my peer supervisors and provided feedback to me (especially my wife Chris, a previous president of the American Board of Professional Psychology, who I believe is the best therapist I know). As the contemporary saying goes—“I appreciate you!”.