What works in therapy?
When I graduated as a psychotherapist in 1990 I had been taught a lot of things that were never much use in therapy – watching out for ‘transference issues’ was one of them. I had also not been taught a lot of things that I really needed to know, but only found out later. So like most therapists I had to improvise in addition to taking a lot more add-on courses. But now I have been doing it for 23 years I have learnt a few things I am going to share with you.
Here is my list of seven things that matter in therapy.
1. Focus on real life problems
People don’t come to therapy because something went wrong in childhood; they come because they are miserable now. A surprising number of people with unhappy childhoods (I am one of them) turn out to be resilient individuals who find happiness later on in life. Now people who are anxious, depressed, addicted, obsessional etc are usually so because a) they learnt to do the wrong things, or b) they are unable to cope with the problems life inflicts on them. If they don’t know how to stay out of depression, for example, you need to teach them the skills required. If they are suffering because they are bereaved, lost their jobs, divorced or can’t cope with their children then therapy should focus on showing them a better way to handle these problems.
2. Therapy should be educational
Therapy is a matter of learning what not to do, and learning what to do instead. For example, Anxiety is mostly caused by bad thoughts and an overactive nervous system; changing those thoughts takes away the trigger for the anxiety and practicing mindfulness reduces arousal. Solutions also exist for depression, drug and alcohol addictions, post-traumatic stress and all the other conditions commonly treated in psychotherapy. If the client’s misery arises from life problems then we show them how to handle them better. Sometimes that involves teaching them better communication skills so they can manage people better. At other times the therapist becomes a coach: helping them find a new partner, a new job or a new set of parenting skills. Effectively, you are helping clients to become their own therapists.
3. The client does most of the work
I really wish I’d know about this one from the start. It would have saved me a lot of grief and a lot of worry. Given that burnout syndrome is the main reason people give up doing therapy it is important to know that the therapist is not the main reason why clients get well; the client is. The fact is that many people do not use therapists but get well anyway. They do that by making changes at work or at home, getting support from their partners, friends or families, or finding a new direction in life. And sometimes that happens purely by accident, as with the severely depressed client I once worked with whose problem disappeared overnight when her bullying boss was sacked.
That is why I always end every one of my sessions with an assignment list. Things to do, things to find out, things to practice, etc. Making the arrogant assumption that the therapist is responsible for change is a sure way to create needy, dependent, fearful clients whose therapy goes nowhere.
4. Avoid theories in therapy
I quickly learned that, for most people, too much theoretical explanation (jargon) is a real turn off. You can help people with practical explanations – for example, showing them what happens to their sleeping pattern when they get depressed, or showing them how a phobia is created. What you don’t want to do is give them psychobabble, psychiatric labels or an offload from the psychology article you read the day before. As one of my mentors once told me: explanations are the booby prize. They are what you get instead when nothing happens, and you don’t change.
5. Keep it brief
The mode number of therapy appointments (that is the most common number of sessions clients have) is – wait for it – One. That’s right, many people who turn up for therapy have just one session. This can be a problem for new therapists, who often tear their hair out and wonder whether they made the wrong choice.
Then, about twenty years ago a researcher in the US decided to contact lots of people who hadn’t come back for more therapy, and asked them why. The majority said that the reason was that they had got all they wanted from the first session. Some said it was encouragement or reassurance, others said good advice, more said that after one session they were cured. Relatively few people said it was because they didn’t like the therapist, or because it was a waste of time. It has also been estimated that something like 70% of the benefit clients receive from therapy occurs in the first three sessions.
For my part, if the client is not showing signs of improvement after two sessions then I know I am doing something wrong. Naturally, some clients need more time than that, but most do not.
6. Use a different approach with every client
Most approaches in therapy follow a single formula, a step-by-step method that is drilled in to you on therapy courses. Trust me when I say that for every client for whom it works you will find at least two more for whom it doesn’t. Nearly all the other experienced professionals I know no longer use the approach they were trained in originally, even though they are still registered with that training organisation! Instead they adapt their approach to the client sitting in front of them.
Some people, for instance, need lots of direction while others will get irritated if they think you are telling them what to do. Some clients like you to help them with problem-solving, while others want you just to listen. Some clients need lots of nurturing, while others need you to challenge them and have them reconsider their activities.
This is really the one thing you just can’t teach people on therapy training courses, it only comes with experience.
7. Make it fun to do
This was another early learning experience for me. When I first started out I had the idea that therapy was a terribly solemn business. It all had to do with the delusion that I was in practice in order to rescue the human race and save the planet. The other delusion, of course, was that I was a Merlin the Wizard character with the power of life and death over the fate of my clients (most therapists don’t in fact know that much more than their clients do).
The problem with delusions like these is that you get badly spooked when your magical powers turn out not to work. In fact I got so stressed that after two years in practice I gave up doing therapy for a while. Another problem is that with this attitude you won’t come across to other people as a human being.
Gradually I learned to keep things light-hearted and just be myself. But more important than that I learned the value of humour in therapy. If you haven’t got your clients laughing most sessions then there really is something wrong.