I am rarely asked the question – “Does psychotherapy work?” Yet, the issue of therapeutic effectiveness is a question people should be asking given the enormous investment, financial, practical and emotional that it requires them to make. I am curious that this issue does not get discussed more often than it does, both with clients and among therapists themselves. To our shame as an industry, outside of the rarefied atmosphere of research studies, most therapists still do not evaluate therapeutic outcomes routinely across their practice. No wonder some people considering entering therapy are sceptical. For others, they may have had a poor experience in therapy and they have been left doubtful that psychotherapy might make a difference to their situation.
Research over time has shown consistently that about 85% of the time, therapy does ‘work’ (1). People who undergo some sort of therapy tend to do better than those who just wait for time to ‘sort things out’ and leave that as their only intervention. This finding has been found to be the case across most of the different kinds of psychotherapy approaches used by therapists with clients (2). Predictably, effectiveness is majorly affected by client characteristics and also by context.
What do we mean when we say therapy works? When I meet a new person or a couple, I look at all aspects of their life – how they feel about themselves; their health; their relationships with their partner and children (if they have them) and family of origin; how connected they are to a community of friends in a network of meaningful relationships. I listen to the way they speak about their work (if they have any) and whether it is fulfilling for them. I listen to their relationship with their body, their sexuality, with their roots (cultural, race, religious) if this is important. I listen for clues about whether they are friendly towards themselves, their roots, or whether they have internalised rejecting attitudes towards those areas of their life?
I listen to their story about their life history and how they tell it – is it a hero story of overcoming difficulties? Or is it a story of victimisation and powerlessness? I listen for clues about how they answer what Einstein thought to be the central question remaining for humanity to answer – “is the Universe a friendly place?”(3). How people answer that question usually shows up in their approach to the world, to new relationships and new environments, in the ways they comment about their expectations of what might happen and how they prepare for life, relationships, and new experiences, and how they view challenges they face.
In life, we tend to experience and find what we expect to find.
In English, there is a saying: “I’ll believe it when I see it”. In my observation, there is often a self-fulfilling prophecy between what we expect to find and what we ‘see’. A case of “don’t confuse me with the facts, I’ve made up my mind” which can blind us to opportunities and blessings, as well as dangers. I want to know what my clients believe about themselves, others, relationships, life, the world. In my experience, it is often those beliefs that dictate what we see, what we will find, and what opportunities we will avail ourselves of, as well as what options we think will be available to us. These beliefs also blind us to what might be true and what we might be able to do, what might be possible, thus keeping us unnecessarily trapped in painful circumstances. The ‘work’ of therapy occurs largely at the place where the person deals with the world and how they deal with the world they find.
Therapy ‘works’ when people are able to change their circumstances for the better in ways they were previously unable to do, and/ or they change their response to their circumstances – and usually, for therapy to ‘work’, most people need to do a mix of both.
Whether therapy works depends significantly on the relationship between the two parties involved-the client and the therapist. If that relationship isn’t good (we call it the therapeutic alliance), then the chances of therapy working i.e. helping you get you the outcomes you want to have in your life, are very much reduced.
Therapy, in my view, is not something that can be done in a manualised form. When it comes to human relationships, emotions and the mind, we cannot approach human beings with a ‘one size fits all’ approach to the issues they struggle with. The relationship between a therapist and client is so important that it can make the difference between a successful outcome and an unsuccessful outcome (4). As such, it is best if the therapy is tailored to suit the particular client(s), the issues they bring, the resources and challenges they bring to the table, and their particular set of circumstances. Without this kind of orientation on the part of the therapist, the effectiveness of therapy will be very limited.
There are times when I hear that a therapist has previously tried to work with what is now a new client of mine, but it went nowhere according to the client now sitting in front of me . At those times, it’s usually a case of the relationship between me and the new client being experienced by the client as a better fit than the one they had with their previous therapist. Conversely, when I fail with a client, and I do at times, I am sure it has to do with me missing a key piece in our relationship and inadvertently making the person feel uncomfortable, or that I am not ‘getting’ them or their issue in some essential way.
In an effort to reduce the times I ‘miss’ clients, I use an evaluation tool that tracks both the changes in the person’s wellbeing across several areas of their life over the time we work together, and also how they experience me, our relationship, and my approach 5 . We do this every time we meet. If I find either we are not getting the person the results they want, or they identify something I need to change in my approach, then we talk about it and I do whatever I can to make the changes I can make to try to course-correct. By making the repairs and adjustments I need to make as soon as I find out about them, we are usually able to ensure that the person/ couple get what they came for from our work together.
If you’re considering entering therapy with a practitioner, or you are unhappy with your previous or existing therapy results, what can you do to make sure that your therapy works? Here are some pointers –
1. Make sure you tell your therapist what it is you want to have change. It might sound basic but, if you don’t set clear goals, then you are not going to have a clear way of assessing whether or not real change has occurred;
2. Be an active participant – no therapist can know what to do for each person they meet. Therapy is a collaborative process. If you are unsure about how things are going in therapy, or you don’t think the direction the conversation is taking is useful or relevant to your concerns, speak up!
3. Be brave – dare to raise the issues you know you need to look at. Or accept that things will remain the same. The therapist can only work with what you bring to them.
4. Feedback is an essential part of getting and keeping therapy on track (6) . If you are not sure or you don’t like something, saying so gives both of you the greatest chance to course-correct. If you don’t say anything, you will not only have to put up with the results, but chances are you will have condemned yourself to more of what you grew up with. Why do that AND pay for the privilege this time? Remember – you will get what you settle for;
5. What you do in between sessions is as important as what you do in sessions. Don’t expect things to change if you don’t implement the things you discuss in therapy. Big realizations are fine – but they have to be followed up by action in your life out in the world or it’s all just shooting the breeze;
6. Good therapy happens in a space that’s safe but not too safe. By this I mean you need to feel safe enough to explore things you know you have to address that you feel uncomfortable about, but not so safe that you end up staying in your comfort zone, doing nothing to change your circumstances. Being uncomfortable is par for the course in a therapeutic conversation. Sometimes, you will hear challenging feedback – as long as you feel respected, and the feedback seems directly relevant to what you are bringing to the table, then expect to feel somewhat uncomfortable, particularly when your own contribution to your difficulties is under the microscope.
7. If you feel you’ve done all of this and you’re still not getting anywhere, then say so openly and either ask for another referral to someone else or go looking for another therapist, one better suited to your needs. Don’t stay on in a situation that’s not getting you what you need;
8. And if you do jump ship and decide to trial out another therapist, tell them up front what you’re looking for, and what didn’t work for you the last time so they can try to make sure that the same thing doesn’t happen again. And monitor how things go the next time – you should be seeing results for your efforts.
And if you know it’s time to do something and make some real changes in your life, call me.
1 Norcross, J.C. (Ed.). (2011). Psychotherapy relationships that work: Evidence-based responsiveness (2nd ed). New York: Oxford University Press.
2 Wampold, B.E. (2001). The great psychotherapy debate: Model, methods, and findings. Mahwah, N.J.: Lawrence Erlbaum Associates
3 Albert Einstein, cited in a reading onhttp://www.awakin.org/read/audio.php?op=play&tid=797
5 http://www.whatispcoms.com/get-the- pcoms-measures/
6 Lambert, M.J. (Ed.). (2004). Bergin and Garfield's handbook of psychotherapy and behavior change (4th ed.). New York: Wiley.
“Predictably, effectiveness is majorly affected by client characteristics and also by context.”
Perhaps I read this wrong but it comes across as an easy out for the therapist so they may avoid looking at why therapy wasn’t effective. The lack of therapeutic effectiveness is related to client characteristics? Is that what it meant to say? There were no other reasons presented as to why the therapy wasn’t effective except the word “context” which is also ambiguous.
Thank you for your question!
To be fair, the whole issue of therapeutic effectiveness is one that is hard to do justice to in a blog post. Entire books are devoted to the subject – books by Scott Miller, Barry Duncan, and John Norcross respectively will more than address your questions and do so far more adequately than I can in a blog post or in this brief reply. My reference to client characteristics as well as context was a quick way to acknowledge that there are more factors impacting therapeutic effectiveness than those that are controlled by the therapist. An example of client characteristics is if the client is mandated to attend, for example, such as a drink driver who has been sent by the courts. This will likely impact whether therapy is effective or not -the client’s willingness to actively participate in the process being a case in point in such instances. Certain contexts also make it much harder for therapy to be as effective relative to other contexts – trying to do therapy in a busy and noisy office where there are lots of interruptions, for example, or confidentiality is hard to maintain, or where trust is hard to build because the client is not necessarily there willingly (such as in jails, remand centres for young people). The wider social and political context in which the therapy takes place will also impact the therapy – if the person is afraid of being persecuted for the issues they wish to discus, it will make it much harder for them to open up and do the work they need to do. Imagine being a gay person wanting to work on issues about their homosexuality in Chechnya right now, for example.
I hope I have come some way to addressing your question.
Thank you for asking for clarification.