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At some point in our cultural history, the relationship of one person helping another evolved to a point at which one person was officially designated as a helper. Helpers developed particular expertise, whether it be in fixing a broken wagon wheel, tracking game, healing illness, offering spiritual or emotional guidance. In the latter case the mental health helper was likely an individual particularly blessed or gifted in his or her ability to assist others through trying times. Reliable research demonstrates that psychotherapy, or the guidance offered by mental health professionals, is neither unproven nor a luxury, but in fact a viable, empirically supported intervention.
The movement toward empirically supported or evidence based treatment is gaining momentum world wide, particularly in health care professions. Insurance companies are providing greater oversight in an effort to improve outcome for mental health issues. This reflects not just an effort to contain costs but a broader movement in which the insurance carrier is a consumer and the mental health provider a compensated employee directed at providing effective treatment for specific types of problems. The American Psychological Association has led the way in identifying empirically supported treatments and publicizing these treatments.
However our efforts thus far to identify evidenced based practices in mental health treatment are incomplete in three ways. First, practice guidelines are “personless.” They depict disembodied professionals performing “procedures” for individuals with specific mental illness. It is understandable that efficacy research goes to great lengths to eliminate individual therapist variables that might predict success, such that if a treatment is deemed to be effective we can be assured that it is not the therapist’s style but rather the treatment facilitating healing. However, this practice may be equivalent to throwing the baby out with the bath water. Multiple and converging lines of evidence indicate that the qualities of the psychotherapist are probably better indicators of successful treatment than the type of therapy provided. Researchers have identified that therapists’ qualities overshadow treatment models in predicting success.
Second, research efforts have focused upon validating the efficacy of treatments or technical interventions as opposed to understanding the therapy relationship or the therapist’s interpersonal skills. Yet, the largest percentage of outcome variance not attributed to pre-existing client characteristics involves individual therapist differences and the relationship developed between the therapist and client.
Finally, practice guidelines have been built around psychiatric conditions rather than around people. Diagnostic protocols in the technical manuals may be efficient for grouping individuals by symptoms and impairment but do not provide much insight in explaining differences in outcome among individuals with similar diagnoses.
Below are seven key findings in over ninety studies of psychotherapy demonstrating the importance of therapist qualities.
• There is a significant relationship between the therapeutic alliance and therapy outcome.
• Therapists who provide empathy have better outcome.
• Therapists who work toward a consensus and agreed upon set of goals with clients have a better outcome.
• Therapists who are warmly accepting of their clients without conditions have a better outcome.
• Therapists willing to share of their lives and are genuine and communicate their person to clients fare better.
• Therapists who provide consistent feedback are more successful.
• Therapists willing to accept responsibility in part when things do not go as planned have better outcome.
The current practice by insurance carriers of limiting psychotherapy visits is ineffective. In fact, individuals who manifest impairment in two or more important areas of life are likely in need of much longer and intensive courses of psychotherapy.
A task force report about psychotherapy by the American Psychological Association in 2002 closed with a four key recommendations. These are worth repeating.
1. Therapists are encouraged to make the creation and cultivation of a therapy relationship characterized by the elements found to be demonstrably and probably effective a primary aim in the treatment of patients.
2. Therapists are encouraged to adapt the therapy relationship to specific patient characteristics in the way shown to enhance therapeutic outcome.
3. Therapists are encouraged to routinely monitor patients’ response to the therapy relationship and ongoing treatment.
4. Concurrent use of empirically supportive relationships and empirically supported treatments tailored to the patients’ disorder and characteristics is likely to generate the best outcome.
Children and adults can and do benefit from psychotherapy when appropriate diagnoses are made, related life issues are understood, therapists possesses sufficient knowledge of the condition being treated, an appropriate treatment plan is developed and in particular, the therapist understands the critical human role he or she plays facilitating the treatment process. However, because of continued generic licensing and credentialing processes, not all psychotherapists are equal in their knowledge, techniques or understanding. Further, profit driven managed care insurance plans often limit not only the number of visits but the professionals an individual can access. These phenomena may work against good outcome in psychotherapy. When I am asked to recommend a therapist, I am careful to not only suggest individuals whom I know well and trust but to also suggest the person seeking therapy enter the first visit with a series of questions about the therapist’s background, training, mindset and ideas about treatment. Psychotherapy is first and foremost based on trust and the development of a working alliance. The foundation for confidence in a therapist is often based upon initial first impressions.
In our work together, Dr. Robert Brooks and I have focused increasingly on the therapist’s role in facilitating a resilient mindset in individuals struggling with life problems regardless of the therapist’s treatment model. Thus, we increasingly view psychotherapy as an opportunity for individuals to not only have specific problems addressed but to learn a broad set of thinking, feeling and interactive skills to facilitate stress hardiness. In our work we have increasingly focused on helping children and adults in therapy, develop a set of assumptions or attitudes about themselves that will positively influence their behavior and ultimately their lives. We believe that in turn their behavior and the skills they develop will influence the set of assumptions they possess so that a dynamic process is constantly operating. We have come to call this set of assumptions “a mindset.” Interested readers can examine any of our books, including our work for adults, The Power of Resilience (McGraw Hill) and for children Raising Resilient Children (McGraw Hill). We have come to understand and believe that individuals possessing a resilient mindset feel control in their lives. They are empathic. They communicate adequately. They know how to problem solve and make decisions. They are capable of establishing realistic goals for themselves. They learn from success and failure. They are compassionate, responsible and connected to others.
Seeking psychotherapy is frequently a decision made when problems persist, intensify or cause significant impairment. It is not an easy choice. However, seekers of such help can be assured our field is and will continue to refine effective techniques and strategies while maintaining our human touch.
