6
This book has discussed the role of theory in the process and outcome of psychotherapy. Loosely speaking, psychotherapy is an interpersonal interaction between a therapist and a client that is aimed at alleviating the client’s suffering. However, it is not simply a conversation; therapy has form and substance created by the therapist’s theoretical orientation. A relatively young profession, psychotherapy has been characterized by a rich array of theories. These theories are quite different philosophically, scientifically, and procedurally, as the book has discussed in some detail. Psychoanalysis, as developed by Sigmund Freud, was created in a medical context in Europe and displaced faith-based and spiritual talk therapies in the United States. However, the hegemony of psychoanalysis did not last long. The behaviorists, steeped in learning theory and scientific psychology, sought to lend scientific legitimacy to psychotherapy. Despite a few attempts to integrate behavioral and psychodynamic approaches, much antipathy between the schools existed. After World War II, humanistic approaches that focused on the meaning of life and phenomenology became a third force. To add to the array, postmodern approaches have emphasized multicultural counseling, social contexts, and issues of power and oppression. Within each broad category are many theories—and more are being developed. To add to this diversity, there are eclectic, integrative, and transdiagnostic approaches. To say the least, the theoretical landscape is vast.
The process of psychotherapy is guided by theory; without theory, there is no psychotherapy. The theory provides the road map for the therapist. An understanding of the client’s problems is saturated with theory, and, consequently, case conceptualizations are theoretically based. Treatment actions similarly are derived from the theory used. In a profound way, the entire enterprise of psychotherapy from the case conceptualization and treatment planning to each therapist response emanates from theory.
Given the importance of theory and the multitude of theories, how does one choose a theory to use? There are two perspectives from which to find the answer to this question. The first is the therapist perspective. Each therapist needs to select a theory that he or she finds comfortable and appealing. An intellectual appeal flows, most likely, from a philosophy of science that forms the basis of theory. Furthermore, each theory has a worldview, which should be compatible with the therapist’s attitudes and values. Moreover, each theory demands a skill set to deliver it; cognitive behavior therapy (CBT) involves structure, whereas humanistic theories require a presence in the here and now—and therefore a match between therapist characteristics and theory is needed. The theory used must be effectively enacted; that is, it is essential that the treatment delivered benefits the client. The therapist perspective can be summarized thusly: The therapist should be passionate about the theory and be able to deliver the corresponding treatment effectively.
There are different considerations from the client perspective. Any person presenting to a healer expects an explanation and corresponding actions in the frame of the healing practice. That is to say, psychotherapy clients expect a psychological explanation for their difficulties and some psychological intervention consistent with that explanation. However, not all psychological explanations are equally acceptable to a given client—and acceptance by the client is critical. Concordance with the client’s worldview, culture, and preferences needs to be considered. For example, some clients will respond well to the structure of CBT and prefer the teacher/consultant role of the therapist. Others might expect therapy to involve introspection and benefit from the emotional connection to the therapist, and thus respond better to an experiential/humanistic therapy. Multicultural counseling and psychotherapy recognize that all therapy must be culturally relevant and sensitive. The therapist must assess the acceptance of the treatment by the client and be sensitive to client resistance to the treatment; if the client does not respond to a particular theoretical approach, then the therapist must adjust the therapy accordingly. Of course, the skilled therapist presents the rationale and treatment convincingly. Nevertheless, therapists should be competent to provide more than one treatment to accommodate variability in the client’s attitudes, values, context, and preferences.
Related issues exist around the compatibility of the treatment for the therapist and the client. Besides the critical issue of acceptance, the explanation should be adaptive. Often clients present to therapy with explanations for their problems that lead to the conclusion that there is no solution; indeed, clients often present when they feel that their problems cannot be solved and all attempts have failed. For instance, an older engineer who was extremely depressed about his current employment setting had returned to school to complete a master’s degree. He was doing poorly in classes, and his “imminent” failure would lead to his having to remain in his current position, an extremely discouraging outcome in his mind. His explanation for his poor performance involved his age (i.e., “I’m older than all of the other students by at least a decade”) and his lack of intelligence (i.e., “These days, students are smarter”). Clearly, the client could not change his age or his intelligence (and neither could the therapist). An alternative, adaptive explanation involved attributing his poor performance to his lack of time to study and his disorganized and seemingly uncontrollable personal life. The explanation itself resulted in increased hopefulness—remoralization in Jerome Frank’s terms or increased self-efficacy to complete the necessary tasks in Albert Bandura’s terms—because the client could take action to address study time and his personal life.
Psychotherapy also involves a treatment that instigates healthy client actions. To be successful, the treatment must be consistent with the explanation. The particular treatment and client actions differ according to the theory used. For the engineer, CBT was an acceptable treatment because the client was instrumentally oriented, responded to structure, and appreciated the teacher/consultant role—he did not want to be “psychoanalyzed.” The therapist was able to use cognitive techniques to change the client’s attributions about his poor performance and implemented strategies to organize and exert some control over his personal life (e.g., assertion skills) to facilitate increased study time and better performance. Of course, the increased control over external events was pleasing to the client, regardless of his classroom performance.
What is not important is the truthfulness of the theory. As discussed in this book, truthiness is a problematic term because the various psychotherapy theories are derived from incommensurate philosophies of science. What qualifies as truth in the respective theories differs, so there is no resolution possible. The review of the research also showed that no particular theory or treatment approach appears to be empirically superior to any other, despite concerted attempts to identify particular treatments for particular disorders that consistently produce better outcomes. Despite this evidence, the therapist should believe that the particular theory, as it is being applied by the therapist in this particular case, is effective. There is empirical support for that contention.
Decades of clinical trials have shown that psychotherapy is remarkably effective. Generally, it is more effective than many accepted medical practices, is as effective as medication for many mental disorders, is more enduring than medication (i.e., the relapse rates are lower after the treatment is discontinued), and is less resistant to additional courses of treatment than is medication. The average person who receives psychotherapy is better off than about 80% of those who do not. Furthermore, psychotherapy delivered in naturalistic settings seems to produce effects comparable with those achieved in clinical trials. All of this is to reiterate: Psychotherapy is remarkably effective.
Again, despite numerous clinical trials comparing psychotherapies intended to be therapeutic (i.e., treatments with legitimate psychological rationales given by trained therapists who have an allegiance to the psychotherapy), it appears that all of the approaches are about equally effective. This seems to be true, despite the disorder and the nature of the treatment; no one approach is clearly superior to any other. This seems to true in real-world settings and clinical trials. Clearly, treatments that have been tested and found effective in clinical trials have achieved a distinction worth noting, but as discussed in this book, the important question is whether a treatment is effectively delivered by the particular therapist.
Attempts to establish the specificity of particular ingredients of psychotherapy have failed to show that the specific ingredients are necessary to produce the benefits of psychotherapy. When the purported active ingredients are removed from an established treatment, the benefits remain; for example, removing the cognitive components of CBT for depression does not attenuate the benefits. Moreover, it does not appear that particular treatments are mediated by the hypothesized systems; for example, CBT does not seem to be effective because it changes cognitions in ways that other therapies do not. This is not to say that the specific actions in therapy are unneeded. There is research to show that cogent and coherent treatments focused on the client’s problems, which are consistent with the explanation provided to the client, are absolutely necessary.
If the particular treatment is not critical to outcomes, what makes psychotherapy work? Evidence indicates that factors common to all therapies are therapeutic, particularly the therapeutic alliance, a sophisticated set of interpersonal skills, and the person of the therapist. The therapeutic alliance comprises the bond between therapist and client, agreement about the goals of therapy, and agreement about the tasks of therapy. Essentially, the alliance represents a collaborative relationship between therapist and client, resting on the client’s acceptance of the explanation provided by the therapist and the concomitant treatment. Research on the alliance has shown that early establishment of the alliance (i.e., at about Session 3) is related to the final outcome. Moreover, this relationship is found across therapies, including CBT and behavioral treatments, as well as more relational therapies, such as humanistic and dynamic therapies. Indeed, the alliance is related to outcomes for psychopharmacological treatments of mental disorders. This research suggests that the particular therapy approach is less important than the collaborative relationship than is built with the client. Keep in mind that the alliance is more than a relationship with an empathic therapist: It is agreement about the goals and tasks of therapy, which comes back to acceptance of the explanation and of the treatment.
Chapters in this book have emphasized that how the therapist delivers a particular treatment is critical. The therapist’s skill in delivering the treatment is more important than the particular treatment itself, suggesting that there will be variability in the outcomes produced by therapists. Indeed, clinical trials have found that there is significant variability in the outcomes produced by therapists within treatments; that is, some therapists giving the same treatment (e.g., CBT) consistently produce better outcomes than other therapists. Moreover, variability in outcomes due to therapists is much greater than any variability in outcomes due to the particular treatment. This is surprising because in clinical trials, therapists typically are selected for their skill, are trained, and are supervised and monitored to ensure adherence to the treatment protocol. These clinical trials and the research in naturalistic settings suggest that therapists are key to creating the benefits of psychotherapy.
As discussed in this book, the therapist effects raised the question about what characteristics and actions make therapists effective. It appears that therapists who achieve better outcomes are better able to form a working alliance across a range of clients and have a set of interpersonal skills that they can use with challenging clients.
Clearly, there are many unresolved issues in the field of psychotherapy, which creates debates among psychotherapy researchers and practitioners. Nevertheless, mental health professionals are committed to improving the quality of mental health services, which raises possibilities for future development and research. Of course, the search for more effective treatments will continue. The improvement of existing services by providing therapists with feedback about client progress is being deployed in many settings around the world. Others are trying to enhance the quality of mental health services by assisting therapists to improve through deliberate practice. These initiatives are important, but it must be kept in mind that, regardless of the effectiveness of psychotherapy, there remain structural problems with the mental health system and society more generally. Access to mental health care is a problem that needs to be addressed. Most people with a mental health disorder do not have access to adequate care or do not seek such care. Increasingly, citizens of developed and developing nations are facing increased stress from pressure to work more, conflicts between countries and within countries, homelessness (due either to poverty or conflict), and trauma (e.g., family and interpersonal trauma, war, shootings, or military actions). Moreover, people are becoming more socially isolated, a risk factor for physical and mental health pathology.
As explained in earlier chapters, therapists need to have a thorough understanding of psychotherapy theory and be able to use that understanding to benefit their clients. Psychotherapy trainees, although they appreciate the many issues in the field, will need to focus on learning various approaches, both intellectually and in practice. The process of becoming an effective therapist is a lifelong pursuit that involves deliberate practice. The goal is not to select the “right” theory but to learn to use a particular theory—or more likely, theories—effectively. Time is better spent learning how to be a psychotherapist than debating the relative merits of the various theories!
The books available in this series present a rich array of theories from which to choose. Readers will resonate with some and find others less appealing. Keep an open mind and appreciate the diversity of the approaches. They all have something important to offer.