How Therapy Works
This might be a little long, and a little “out there,” but I thought I’d share parts of an essay I recently wrote describing some of my beliefs about the nature of therapeutic change: Like many things, I believe that change in therapy is multiply-determined, and that, as the Buddha opined, there are many paths to enlightenment (change).
In conceptualizing how this whole process works, I rely first and foremost on common factors theory and Lambert’s outcome research which approximates the relative contribution of client factors (40%), the therapeutic relationship (30%), specific techniques (15%), and the placebo effect (15%) to therapy outcome. For me, the takeaway messages from these data are: (1) that clients contribute a lot to the process of change, for better or worse, (2) who I am in the therapy dyad is as important as, if not more important, than what I do, and (3) hope is important.
In a perfect world, therapy is built upon the foundation of a trusting, warm, collaborative alliance, to which each member of the dyad contributes something real. Regardless of whether I conceptualize individuals’ concerns as stemming from distorted thinking, dysfunctional relationships, or defense systems run amok (to name a few), I need to build a strong therapeutic relationship, otherwise I (and my client) will struggle greatly to effect change. Of course, I also need to have some idea about what I’m doing (specific techniques); I can’t just declare some variation of, “Eh, so long as the relationship is strong, change will occur” and call it a day. But I have a good deal of flexibility in what techniques I choose. I know that therapy cannot be a one-size fits all endeavor. To that end, I tend to gravitate toward what works, and invite my clients to contribute to determining what works for them.
But now I’m starting to get circular about the whole thing. Saying I do what works brings me back to the question of how it works, whatever “it” might be. In the most generic sense, I see therapy as a forum in which my clients and I team up against the problems or concerns that clients bring to the space. Clients don’t just bring concerns; they also bring expertise on their own lives – what has helped in the past, what feels like progress and what doesn’t. I bring expertise on the process of change, and offer hope that change can and will occur. Together, we process, experiment, practice, and re-work new ways of being for the client – new ways of thinking, feeling, or behaving. People can get stuck – in old habits, old ways of thinking, old relational dances – and they often don’t know how to break out. As a therapist, I attempt to create a space in which reflection and taking risks are honored, hopefully such that clients discover new perspectives or new momentum, and once again move forward in a way that is meaningful for them.
When it comes to roles within the therapy process, in the words of Yalom, I view myself as a “fellow traveler” with my clients. I am an imperfect being trying to make my way through this world, and so are my clients. That being said, I acknowledge the power differential that is inherent in the therapeutic endeavor, and strive to use my powers for good, as it were. In other words, I attempt to meet clients where they are at, and then try to use my influence to push them a bit further, to consider an alternative view, to practice some new skills, to learn a little bit more about how they operate in the world, and what is important to them. I listen – of course I listen. I sit, a lot, with people’s grief and pain and mucked-up feelings. I teach, encourage, and cheerlead. I watch and I wait.
In the best of all worlds, clients take on the role of engaged seekers. They are active learners, thoughtful reflectors, and willing participants in the process of change. They are committed to increased knowledge, understanding, and compassion, both of themselves and of others. Of course, in reality they are, probably more often than not, reluctant to look at themselves, ambivalent about change, and uncertain about what they really want. And why wouldn’t they be? So-called change, or progress, is often ill-defined, murky, or ambiguous, given the complexity of human emotion, thoughts, behaviors, and relationships. It can be tricky to define and trickier to achieve. This is where hope, and perhaps faith in the process and relationship, become important.