What Makes Psychotherapy Work?

Friday, June 16, 2017 @ 09:06 AM  posted by Dr. Siders

Choosing the right therapist can be a difficult and daunting task.  After looking at a therapist’s qualifications, certifications, and degree, to some extent, your selection of a therapist is about finding the right fit because everyone is unique.  A therapist who is right for someone else may not be right for you and vice versa.  But how can you tell which therapist will be the right fit for you?

One of the main factors that differentiate therapists from one another is theoretical orientation.  Theoretical orientations are belief systems that define how a therapist views mental illness, causes of mental illness, and the best ways to provide treatment.  Currently, there are hundreds of theoretical orientations, but most therapists identify themselves as a specialist in one of the five or six most common orientations (psychodynamic, cognitive behavioral, behavioral, humanistic, and eclectic. For a mostly jargon-free description of these orientations, see https://psychcentral.com/lib/types-of-therapies-theoretical-orientations-and-practices-of-therapists/ ).

Naturally, clinicians and researchers alike are interested in determining which theoretical orientation works the best.  Hundreds of studies have been conducted to find out exactly that.  But much to the disappointment of those hoping to prove their techniques as superior to others, the vast research found no clear “winner.”  While many studies found a small advantage for evidence-based therapies such as cognitive behavioral/behavioral techniques, the other studies concluded that all therapies were roughly equally effective.

Does this mean that all therapists are equally effective?  No.  More recently, some researchers have looked at a number of things they refer to as “common factors.”  Common factors are elements that are common to most types of psychotherapy. More importantly, these elements seem to have a large impact on whether therapy is effective.  Examples of common factors include patient factors, the quality of the therapeutic relationship, open ended vs. goal oriented therapy, and collaborative vs. hierarchical relationships.  I will briefly define each and explain how each can improve the quality of therapy.

Patient factors:  Patient characteristics are a very important factor in determining whether therapy is successful.  This goes against a medical-oriented view that sees patients as passive recipients of treatment that a doctor provides.  It also contradicts the idea that therapy is about providing a diagnosis and matching treatments to that diagnosis.  According to research, diagnosis has little or no effect on how well a treatment works.  This is not a surprise to those who work with people enough to know that two people with the same diagnosis can be very different.  Some patient characteristics that do impact therapy are the patient’s hope, optimism, persistence, open mindedness, and motivation.  Thus, what the patient brings to therapy is vitally important to treatment success.

Therapeutic relationship:  The therapeutic relationship factor describes the quality of the relationship between the therapist and client.  Is there a strong working alliance (Are the therapist and client working with each other or against each other)?  Is there a strong bond?  Does the therapist have empathy?  Does the client agree with what is addressed in therapy and believe that treatments selected are appropriate?  Not surprisingly, a good therapeutic relationship is quite possibly the biggest factor in determining whether treatment is successful.  Yes, the human factor is important.

Open-ended vs. goal-oriented: Generally, goal-oriented therapy is more effective than open-ended therapy.  Goal-oriented therapy is therapy where you and the therapist agree upon concrete, achievable goals, devise steps for working toward those goals, and measure progress.  If you have been in therapy where you do not have a clear idea of what you are working toward, you may be participating in an open-ended therapy.

Collaborative vs. hierarchical:  Research shows that therapy is most effective when a therapist subscribes to a collaborative view of therapy.  In a collaborative view of therapy, the client is seen as an equal partner in their working relationship.  Of course the therapist is expected to bring their expertise to the therapy room, but your input is an integral part of treatment success.  This contrasts with a hierarchical model of therapy, where the client is seen as subordinate.  The therapist tells the client what to do and the client does it.  You should be an active participant in setting up your goals, and communicate often about whether ongoing therapy should continue or be revised.  Your therapist should check in to see whether you feel the therapy is productive.

An important point to remember is that common factors research does not say that therapist orientation has no effect on therapy success.  Therapists should have a strong foundation in their theoretical orientation and be well-versed in the treatments they provide. However, which theoretical orientation a therapist holds does not have as big of an impact as the common factors listed above.  Ideally, a therapist will be competent in his or her chosen orientation but deliver treatments in a way that develops a client’s strengths, encourages a good collaborative working relationship, and focuses on working on mutually agreed upon goals.

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