I was a psychotherapist for many years. Like others of my era, we went to conferences, watched demonstrations, and read books in an effort to become better therapists. Many of us had years of supervision during school and after graduation. We believed that new research would uncover effective treatments or new components of treatments that would help our clients get well.
Several other factors came into play: medications and managed care.
As medications became more specific for the treatment of common conditions like depression and anxiety, I and others began to wonder about the value of psychotherapy- especially if medication was better or equal to psychotherapy and cost less. In this light, I began to take courses in psychopharmacology in the hope that psychologists could prescribe medication. I worked with others to pass legislation before I decided to retire from psychotherapy.
The second factor was the emergence of managed care insurance companies that gained control of approving psychotherapy visits. Approvals required increasing amounts of paperwork and the payment to clinicians was drastically reduced. For therapists trained in cognitive-behavioral approaches like myself, it was no big deal to provide treatment goals, document interventions, and provide data. Indeed, we considered this "scientific approach" the only way to do psychotherapy. The hassle was mostly dealing with approvals and different forms from different insurance companies.
On average, a person who participates in psychotherapy is better off than about 79% of people who do not get treatment.
This statistic is based on an average effect size of .80 in treatment studies reported by Bruce Wampold, “The research evidence for The common factors models: A historically situated Perspective.” 2010, p. 55.
The secret sauce in psychotherapy is the whole package consisting of five active ingredients.
The fact is, some clinicians are better than others. We know that and yet you do not hear much about it. It's difficult to isolate specific factors. But in common experience we know people who are warm, inspiring, and full of hope. Their enthusiasm can be catching. We also know people who are dull and boring or who appear cold and aloof. Some psychotherapists are also brilliant and full of creative ideas-others not so much.
Findings from the work of Carl Rogers still make sense about the need for a warm and caring psychotherapist. Psychotherapists are also responsible for setting expectations. Expectations are important to outcomes. Psychotherapists are not equally effective. More research is needed on the therapist as a highly important factor.
Relationship (therapeutic or working alliance)
The relationship between a psychotherapist and a client is a critical component in treatment. Many effective outcomes can be traced to the connection made at the first session. As in any endeavor in life involving two or more people, a working relationship is important to success. Research suggests that an effective working alliance depends on the therapist and agreement on the treatment goals and procedures.
Treatment does matter in the context of the other factors. But often a specific type of treatment can be as good as another if the therapist is skilled at the intervention and an organized approach is employed. It's also important that both psychotherapist and client collaborate in the process. The fact that different interventions work suggests there is something about the confidence therapist and client place in the explanation and activities.
Clients (or Patients)
More research is needed about the role of clients in successful outcomes. But we do know that some client characteristics are important. Level of motivation, personality factors, and attachment history are a few factors linked to outcomes. What's highly important is their participation according to Orlinsky and colleagues. Clients are agents who actively shape therapy as they interact with a therapist.
Clients are better at determining successful outcomes than are therapists. Getting client feedback is important to evidenced-based practice.
This is a catchall term for things that happen in life, which can be linked to outcomes. Changes in general health, jobs, relationships, and many other aspects of life can make a significant difference in how people fare during a course of psychotherapy. These factors are beyond the control of the psychotherapist but must be kept in mind if we are to be honest about the role of psychotherapy.
I continue to be in awe of the advances made in modern medicine. I am glad for the progress that helps so many of us live better and longer lives with less pain than in the recent past. There is no reason to detract from the medical model.
But there is reason to realize the important role of psychological factors in wellness overall and in the treatment of those conditions considered psychological (e.g., depression, anxiety). The fact is, at this point in time, psychotherapy is more effective than some medications. And that relationship factors between physician and patient are important for outcomes in general health as well.
I no longer provide psychotherapy. I write, give talks, and consult on research projects
For an important summary:
Orlinsky, D. E., Ronnestad, M. H., & Willutzki, U. (2004). Fifty years of psychotherapy
process-outcome research: Continuity and change. In M. J. Lambert (Ed.),
Bergin and Garfield's handbook of psychotherapy and behavior change (5th ed.,
pp. 307-390). New York: Wiley.
Other related research
Publications (many free downloads)