For decades, psychotherapists and the general public have wondered about the following questions:
1) Does therapy work?
2) If so, how well does it work?
3) How does therapy work?
With respect to the first question, the answer is unequivocally: yes. Beginning in the 1950s, when there was a dominant and somewhat orthodox model for doing therapy, there were critics who questioned whether this approach was as effective as its advocates had claimed. Since then, there has been rigorous investigations into the effectiveness of using psychotherapy as a treatment for mental distress. Generally speaking, what researchers have found is that psychotherapy tends to be highly effective, with comparable results to psychiatric medications but much better long-term benefits (i.e., the benefits remain after treatment ends, vs. taking a medication where the benefits stop when treatment stops).
So we know that psychotherapy works, and we know that it works fairly well. But how does therapy work? This turns out to be a much trickier question to answer than the previous two. However, there does exist some good research on this. The psychologist and researcher John Norcross and his colleagues, for example, have found that there are many variables that may affect (positively or negatively) the results one gets from therapy as well variables that are responsible for the improvements one experiences as a result of therapy. A summary of these variables is reproduced from this book:
As we can see, most of the variance in outcomes (i.e., whether clients get worse or better) depends on what they bring to the table as well as circumstances outside of therapy (i.e., finances, career, relationships, family support etc.). In Fig 1.2., We see that the effects of the actual therapist account for approximately 27% or maybe a third of the total outcome. Does that mean that therapists are unnecessary? Absolutely not. That 30% difference in outcome could mean the difference between someone who is clinically depressed versus a person who is able to experience happiness, health and stability. Think of it in this way: if a car going 60 KPH down the street was reduced to 70% of its speed, it would be travelling at approximately 40KPH. Just try going 20 KPH below the speed limit and see whether the other drivers take notice!
However, it is essential for clients to know that therapy requires active involvement on their part in order to maximize their outcomes. Just as other forms of health care require deep investments of time (e.g., post-surgical rehab, scheduling medication use), doing therapy most often requires a person to make changes to their daily routines, and invest a significant portion of their time and effort outside of the time spent in therapy sessions. In Fig. 1.1., we see again that the most factors for improvement lie outside of the therapeutic session and this makes sense. After all, what is one or two hours in a week compared to all the other hours where the real change must happen? However, if we focus just on the client factors (i.e., excluding techniques that the therapist selects), we see that the behaviors clients make during their sessions may be at least partly responsible for upwards of 45% of the improvements they receive.
So what are these behaviors? Well, roughly speaking, we can break them down into two primary factors:
1) Expectancy (also known as the placebo effect) – expecting a treatment to work has been shown to be one of the most reliable and robust therapeutic agents across all of medicine.
2) Common factors – is also known as the relationship that is developed between the therapist and client. Elements of a successful relationship (which takes work from both partners) generally includes empathy, warmth, having a shared plan, and compatible communication styles. In fact, there is now serious research devoted to not only finding the best techniques but finding the best relationships for different types of clients who enter therapy.
From these factors, Norcross and Lambert have suggested the following recommendations for getting the most out of therapy:
· Seek a therapist who will devote a lot of time and energy to making a good relationship with you as the foundation for the treatment.
· Therapists should routinely monitor their work and how clients are doing through the use of standardized questionnaires and feedback forms.
· Every treatment should be customized to the characteristics (e.g., strengths, learning style, difficulties) of the patient and avoid utilizing a one-size-fits-all approach.
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