“Believe those who are seeking the truth, doubt those who find it.”
– Andre Gide
In The Heart and Soul of Psychotherapy: Delivering What Works, second edition, the author’s review decades of psychotherapy outcome research. The findings clearly affirm the value of psychotherapy. The research indicates that 80% of individuals who receive psychotherapy benefit in comparison to those who don’t. Beyond this reassuring data, the research challenges certain assumptions that many therapists hold as well as assumptions underlying evidence-supported therapy.
The research indicates that psychotherapy effectiveness is the result of common factors that different theoretical orientations share. The effectiveness of different therapeutic approaches is attributed to common factors that activate natural healing resources within the individual. The research does not support the specificity hypothesis that underlies evidence-supported therapy nor the idea that one therapeutic approach is better than another. No single approach is effective for all individuals and each particular approach needs to be tailored to the specific individual in distinction to the often over-generalized diagnostic category to achieve optimal results.
In examining the common factors that are associated with change, the research indicates that client variables are most strongly associated with psychological change. Client variables include factors such as motivation, degree of impairment, and the availability of both internal and external resources. The most important contribution that therapists make is their ability to form and sustain a collaborative therapeutic relationship tailored to the specific needs of individual clients. Somewhat sobering is the conclusion that therapeutic technique and placebo have comparable effects on promoting change and are of much less importance than either client variables or the therapeutic relationship.
Three interrelated research findings concerning the therapeutic relationship are noteworthy and have implications for increasing clinical effectiveness as well as for training.
- It is the client’s perception of the therapeutic relationship and not the therapist’s that is associated with positive therapeutic change.
- Therapists and clients perceptions are not always in agreement.
- Clients tend not to share their negative perceptions with therapists.
The therapeutic relationship is a complex, non-linear, intersubjective process that requires ongoing mutual feedback to optimize clinical effectiveness. Difficulty in this relationship is often imperceptible and not readily communicated. Appearances can be deceiving. When there is turbulence and conflict in therapy, it might signify progress. When therapy is moving smoothly, it might belie collusion and accommodation. Since there is a gradient of disagreement between therapist and client perceptions of the therapeutic relationship, the authors encourage clinicians to actively monitor the therapeutic relationship by eliciting feedback from their clients. Since clients typically don’t share negative feelings about therapy, therapists need to be sensitive to implicit, subtle signs that signal problems as well as to signs that conventionally signify progress. Since clients typically don’t share their negative feelings, therapists need to invite and re-invite them to share their feelings about therapy, both positive and negative. The research indicates that avoidance of these signs leads to negative therapeutic outcomes. Through my practice, I have learned that clients often communicate their dissatisfaction with their feet..
Therapeutic effectiveness derives neither from technique, nor from the elegance or sophistication of our theories. What differentiates effective from less effective therapists is their brilliance but their empathic ability to establish and sustain a therapeutic relationship. Statistics as well as theoretical reconstructions break down at the strange and unpredictable interface where two individuals come together and create what Bion called an “emotional storm.” Contending with this interpersonal storm that is characterized by ambiguity, mystery, and interpersonal disjunction is perhaps one of the greatest challenges of doing psychotherapy. The meaning gap between two individuals is a persistent, subtle and variable component of communication.
Effective therapists face this difficulty with empathy that simultaneously facilitates understanding of the client while enabling them to de-center from their perspective. Am I pushing too hard, am I missing something in the client’s narrative, does what I say make sense to you are questions to pose to clients. They exhibit a quality of humility that allows them to adjust their interventions to the needs of their clients. I have often thought with some clients I work like a CBT therapist might, with other likes an analyst, and others like a friend. The ability to hold lightly not only one’s theory but also one’s subjectivity, what Donna Orange has referred to as “theoretical fallabilism,” creates the space for client’s growth. This ability to de-center, to turn the activity of assertion into the passivity of reception and welcome the presence of the client is critical to therapeutic collaboration and subsequent changes within the client.