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Scott A.

Key Ingredients in Successful Psychotherapy

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A fascinating area of study in psychology is psychotherapy outcome research. These studies look at whether, and to what extent, a given type of psychotherapy is effective, as well as the reasons why. However, in this relatively brief essay I mean to present a fairly simplified model of important “ingredients” in successful psychotherapy. The model comes from a combination of the research literature and my clinical experience.

I honestly cannot say it is unique, as there are many models of effective psychotherapy. I would guess someone has somewhere said something similar to what I will. I mention this to acknowledge that I have not read every piece of literature on the subject, and so do not want to claim that this is “my” model. However, it did occur to me independent of those sources.

In fact, it came about from a discussion about psychotherapy with one of my clients. He asked two interesting and core questions: if psychotherapy works, will I be a different person and why does psychotherapy seem to be working?

My answer to the first question was that he would not be a different person; he would be a broader and deeper person—he would be more consciously aware of his mental states, surroundings, and his relationship to them. This puts him in a position to control or change his thoughts, emotions, and/or behavior (he can also change his environment to an extent). His core self will emerge, which I define (tentatively) as one’s clear judgment, i.e., without distortion.

What I do not recall saying, but could have, is that he might feel like a different person. However, that feeling is what one experiences upon achieving greater mental clarity and pride following the resolution of a significant problem. He will not be a different person, but he will never be quite the same one.

The answer to the second question is the model. There are three core parts to it: motivation, knowledge, and relationship.

Initially, I thought of this in terms of a primary value each person (the client and therapist) brings to the table in a psychotherapy session. Specifically, the client brings motivation and the therapist brings knowledge. A diagram could be as follows:

Client (Motivation) --------------> Relationship <-------------- Therapist (Knowledge)

An unmotivated client is far less likely to change anything and is much more difficult to work with. Even the most knowledgeable therapist will struggle to some extent in treating him. Of course, an unknowledgeable therapist will be of no practical help to the client, who will be further frustrated by the lack of help. Ideally, the client and therapist are strong in these respective areas.

However, psychotherapy is a process, a major part of which is forming a particular kind of relationship with someone. It is a unique relationship in that it is professional, but also (non-sexually) intimate.

Imagine sharing the most secret details of your own life with a stranger. It takes significant trust, and motivation, to do this. Psychotherapists develop and strengthen trust when they skillfully demonstrate their knowledge. They do this in different ways, especially the way they talk with their clients and what they have to say. A good therapist needs to know how to translate what often sounds like mumbo-jumbo into ideas that make sense. He also needs to speak plainly and straight. As soon as a client suspects that the therapist is deliberately not making sense, he will not trust the therapist.

Essentially, a client wants to know that the therapist is a person he can talk to without fear and with confidence that it will help.

This being said, the client’s motivation has to come first. He must want to receive help to overcome his problem. Note that it is receiving help that he must want—he has wanted to solve the problem all along, but did not want any professional help for it. Therefore, the major hurdle to entering therapy is not necessarily a lack of desire to solve a problem; it is acknowledging that one has not been able to solve it on his own.

I actually consider such hesitation a good sign—it means that the person wanted to solve the problem himself, which indicates a belief in self-reliance and the presence of some self-confidence. Those are good things to start therapy with. In contrast, a person who either does not know he has a problem or knows but ignores it will not bring much motivation to psychotherapy.

In addition to some level of motivation, a client also comes to therapy with the expectation that the psychotherapist is an expert (at least compared to the client). This does not mean he thinks the therapist infallible (although some people do look to therapists to be that).

Instead, he needs to see that the therapist knows what he is talking about. It is the same as taking the car to a mechanic—one wants a clear explanation of the problem, how it happened, and what to do about it. Obviously the subject is different, and minds are more complex than engines, but the principle is the same.

Therapists demonstrate their expertise via their communication skills. They show that they understand the problem(s), provide feedback or explanations in everyday language, and help the client understand and overcome the difficulty.

More than this, the client needs to know that the therapist “gets it” and “gets me.” It is good if the therapist understands the problem. It is better if he understands the person.

This speaks to a “common factor” that runs through all psychotherapy success: the quality of the therapeutic relationship. Do the client and therapist like, or at least respect, each other. Clients feel much better about therapy when they like and/or respect their therapists (assuming there is also success). Good psychotherapists want their clients to benefit from, perhaps even enjoy, psychotherapy. Clients and therapists do good work when both want to be there because they see its value and, hopefully, enjoy it.

This last point shows that motivation and knowledge do not solely lie with the client and therapist, respectively. They apply to each person jointly. A slightly revised diagram would be:

Client (Motivation, knowledge) <--------------> Relationship <--------------> Therapist (Knowledge, motivation)

The therapist needs to be motivated to be there, as well. He must enjoy (and hopefully love) his job. He needs to be self-interested in learning about others’ thinking and their lives. He has to want to know about them.

Similarly, the client is better off with some knowledge of his problems and how therapy works. The former is probably a greater help than the latter. However, knowing at least some of what therapy entails will make him better prepared for and open to the process.

If the client does not know much about therapy, then the therapist should take some time to explain it. These are the kinds of things that help develop a solid therapeutic relationship.

Additionally, I have a strong interest in having fun with my clients. I say that with the clear understanding that the kinds of things discussed in therapy are in no way fun. However, because I strongly believe that the therapeutic relationship is an essential ingredient, I also believe that my clients and I can enjoy each other’s company. We can joke, and laugh, and make our time together something we both look forward to. And we also know that strong work will be done.

Both the client and therapist bring values to the process, motivation and knowledge being among the primary. Both not only bring values to therapy, they also gain something from the process. Good psychotherapy is a win-win.

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Very good essay, Scott.

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A fascinating area of study in psychology is psychotherapy outcome research. These studies look at whether, and to what extent, a given type of psychotherapy is effective, as well as the reasons why. However, in this relatively brief essay I mean to present a fairly simplified model of important “ingredients” in successful psychotherapy. The model comes from a combination of the research literature and my clinical experience.

[..]

Both the client and therapist bring values to the process, motivation and knowledge being among the primary. Both not only bring values to therapy, they also gain something from the process. Good psychotherapy is a win-win.

Are these all original insights? I don't see any references, so my guess is that they are. Thank you for sharing them.

Dr. Michael Hurd has written a book, Bad Therapy, Good Therapy. I wonder if you've read it, and, if so, what you think of it.

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I suspect Hurd and yourself, Scott, would have quite a lot to agree about. Both ways, I'd wager. He usually writes about the fundamental aspects of psychotherapy, such as what therapy can and can't do (and why), the acknowledgement of volition, and the general willingness of the client to improve. You've explored the latter and its counterpart in the therapist as well, which I found interesting. In a way, it's a complementary piece to his writings, which is just splendid. :)

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Are these all original insights? I don't see any references, so my guess is that they are. Thank you for sharing them.

Mercury, I honestly can't say these insights are original. As I mentioned at the beginning of the essay, what I wrote is a synthesis of research findings and my own experience. Putting it together the way I did in the essay occurred to me independent other sources (and was based on the conversation I had with the client), but what I said is probably similar to something out there.

I didn't reference research largely because I wasn't intending this to be a more formal, "academic" essay with a literature review. I just wanted to present some basic ideas in a model that makes sense, while acknowledging the general area of research from which many of the ideas come (i.e., psychotherapy outcome research). In any event, I'm glad you enjoyed it.

Dr. Michael Hurd has written a book, Bad Therapy, Good Therapy. I wonder if you've read it, and, if so, what you think of it.

No, I unfortunately haven't read it.

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I suspect Hurd and yourself, Scott, would have quite a lot to agree about. Both ways, I'd wager. He usually writes about the fundamental aspects of psychotherapy, such as what therapy can and can't do (and why), the acknowledgement of volition, and the general willingness of the client to improve. You've explored the latter and its counterpart in the therapist as well, which I found interesting. In a way, it's a complementary piece to his writings, which is just splendid. :)

Thank you, L-C! I have been to Dr. Hurd's website a good number of times and have read things he has written. I suspect we do agree on a lot of things, especially regarding the fundamentals. Coming from the same philosophical base is a good reason for that. I'm glad our writings compliment one another and that you found it valuable. :)

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