How psychotherapy works

ConsultI have been practicing psychotherapy for nearly 30 years now, continually asking myself (and others) the question: how and why and where and when does therapy get results?

Here are some of the things I have learned:

    1. No one technique or type of therapy works all the time (or even most of the time)
    2. The experience of the therapist is more important than any other qualification
    3. Therapists who can work on different levels – thoughts, emotions, relationships, the body/brain, behaviour and the environment are more likely to be effective
    4. Therapists who adapt to the client with different styles of communication: listening, teaching, nurturing, challenging, directing and humorous – are also more likely to be effective
    5. Analysis of past events or ‘the unconscious mind’ is only marginally useful
    6. It is not what the therapist says that is important; it is what the client does with the information given
    7. Most of the changes the client hopes for will come in the first few sessions
    8.  
      It may surprise some readers to know that there is very little evidence that any particular approach – cognitive-behavioural, psychodynamic, counselling, etc., is better than any other. In fact, there is no hard evidence that each approach (on its own) is consistently effective. At present the most funded form of therapy on the NHS is Cognitive-Behaviour Therapy yet a major study in Scotland in 2005 which reviewed the effectiveness of CBT by interviewing clients who had received it 2-14 years before during controlled trials found that the majority of them still had mental health problems.

      At the same time we do know from surveys that psychotherapy, in general, is moderately beneficial. I used that word ‘moderately’ with great care as the evidence is not overwhelming. But it does fit with the perception that there are many good therapists achieving worthwhile results out there. Unfortunately, those outcomes are diluted by poor results achieved in less successful therapy.

      Always allowing for exceptions to the rule, effective therapists will have a lot of experience. It is an obvious fact that if you have spent years holding therapeutic conversations with people from all walks of life with many different types of problem then you are going to be good at it. Malcolm Gladwell’s  “10,000” hours rule springs to mind here. If it takes 10,000 hours (plus natural talent) to achieve mastery in something then psychotherapists seeing a regular 20 clients a week will take 10 years to get there. I don’t necessarily believe that it could take ten years but nor do I believe that it will happen the moment you come out of the training school.

      Given that no one approach will work for all clients (or even for many) good therapists are more likely to have training in different approaches which address different problems and different levels of functioning: mind, brain, body, the emotions and relationships – with many different techniques to match. As therapists come to see more and more clients so they realise the need to do more and more courses. In my own time I have attended courses on cognitive-behaviour therapy, gestalt therapy, stress-management, hypnotherapy, strategic therapy, family therapy, solution-focused therapy, NLP, mindfulness, emotional intelligence and body-focused therapy. To use an analogy: a car repair firm which stocks tools and equipment for many different makes of vehicle will be able to service far more cars than a garage which specalizes in only one make.

      One very common feature of psychotherapy – something that a large number of therapists pursue – is analysis of past events going all the way back to early childhood relationships. In my view this can be counter-productive if taken too far. Knowing why we keep getting into the wrong kind of relationships (for example) is useful and can be liberating when we make the link between what we learnt in childhood with the mistakes we make in adulthood. But too much analysis keeps us trapped in the past: we still need to work on changing how we handle relationships in the present. If we don’t do that then we end up with a great deal of knowledge but very little improvement.

      Good therapists will also be charismatic in some way. That is to say they will have a way of inspiring their clients: through their relational style, their strength of character, their words, their ideas, their insights, their stories, their jokes – and their experience. I notice that many of the good therapists I have met have also been through the school of life and overcome personal suffering of their own. The best therapist I ever met working with drug addictions was himself a former heroin addict. As he once explained to me: ‘I know every which way addicts will try to wiggle out of staying clean as I have tried them all myself.” At any rate therapists like this inspire trust, confidence and hope in the client. Above all they will adapt their style to the client sitting in front of them rather than following a rule-book.

      So far I have focused merely on what the therapist brings to the office. But the best therapist in the world will fail with an uncooperative client. To my mind most research into the effectiveness of psychotherapy focuses far too much on what the therapist does and not enough on the client or on the nature of the therapeutic relationship. Success in therapy really comes from close, collaborative, relationships. And although the therapist must be experienced in developing such relationships much depends on whether the client can do so too. Of course, it helps if the therapist is likeable, approachable and easy to understand. But it is the client who does the work. The irony is that, while the client does the work, it is the therapist who gets the credit for success.

      A common myth about therapy is that it takes (or should take) years to work. In fact most studies show that less is better. One study which looked at therapy for depression showed that clients received all the benefit they were going to receive by the 8th session. Another 2001 study on counselling found that the majority of clients received nearly all the benefit they were likely to have between 7-10 sessions. Naturally, a minority of clients may benefit from long-term supportive therapy but many do not. In fact it is not at all unusual for clients to find that they have achieved their goals within 3-6 sessions.

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