What makes psychotherapy work
The question why some people report making good use of therapy and others do not has been on my mind for a while. I believe it is important to understand what works and what doesn’t in therapy and adjust it accordingly. Research into therapy can help to keep it relevant and up to date.
The following thoughts are based on research by others (*) and my own ongoing research. There are many variables in therapy and accounting for all of them is not always possible, some are very subtle and others remain unknown. The following pie chart is a first attempt at charting some of the known ones, it is a rough estimate. I hope to share more information as I go along.
There are also two quite distinct purposes to therapy, one being healing which relies more on the relationship with the therapist. The other being change, which I believe, relies more on technique and client factors. Isolating these factors is not without limitations because they all interact to create an experience, yet, considering them individually can lead to improving therapy as a whole.
Client factors
By far the most important ones. I believe there are two approaches to therapy and it can be useful to distinguish them. The first is when a client enters therapy with a passive attitude towards their concerns, that is feeling on the receiving end of life. People who feel overwhelmed by their problems would probably assume this role more easily. In this position, good outcome is still possible, however, setbacks are often taken as a reason to feel helpless, hopeless and therefore stop therapy. On the other hand, if people believe they participate in the making of their life, they will become active and trust they can change despite not being sure of any immediate effects. This approach will improve outcome, by far.
Other factors are:
Intention: this is a subtle concept. The immediate intention is not to change, but believe that you can change. The reward of new or renewed abilities comes slowly.
Motivation: of course, a person that comes to therapy show a degree of motivation, but I find that if this is not linked to what is meaningful in a person’s life motivation can easily dwindle by the task. Another factor in motivation is identifying the purpose of therapy and what is to be gained? Sometimes, therapy can cause loss of important past behaviours and relationships.
Resources: these can be caring relationships, family, a sense of belonging, community, resilience, values etc. Lack of support and nurturance thwarts personal growth. Relational psychotherapy has a lot to contribute here, I will write more in my next post.
Natural environment: closely related to Resources, these can be external stressors, sleep, rest, physical activities etc.
Therapeutic relationship
Trust, acceptance and respect are crucial for good outcome and it is very much the role and responsibility of the therapist to earn the trust of their clients – this is not a given but a process that takes small and continuous “deposits” into the relationship. I believe that if you trust your therapist your chances of recovery are better and the margin for error – as in any process – would feel safer.
Technique
There are as many techniques and approaches to therapy as there are therapists, each bringing their own interpretation and personality. Some people want to understand where they come from and others want to know where they are going. So far, I have identified two important factors: the first is awareness. Bringing our behaviour into awareness can make our decisions more ‘choiceful’, which in turn allows less rigid behaviour and more spontaneity. The second factor is ‘making ordinary’, by this I mean accepting the human in us. I personally don’t like the term ‘normalise’ as it suggests that there is one desired and prized behaviour.
(*) Please ask me if you want to know more about the research into therapeutic outcome.
