The Power Couple of Therapy

In therapy, what works best? Is it cognitive behavioral therapy, which reconfigures thinking patterns and habits? Or psychoanalysis, with its sexual and familial focus? The answer is surprising.

Researchers who compare the success rates of various schools find that by and large, techniques and methods don't matter. What does matter is the powerful bond between therapist and patient. The strength of this "therapeutic alliance" seems to spell the difference between successful therapy and a washout.

Figuring out what goes into a good client-therapist relationship is now a hot research topic. It's hard to measure, but a few critical components are emerging.

Likeability and Respect

It helps if the patient and therapist like each other. Therapists have a duty to explore their knee-jerk reactions, probing why they might dislike someone with a whiny voice or a bad haircut. "A good therapist will find something likeable about the patient," says T. Byram Karasu, professor of psychiatry at Albert Einstein College of Medicine and chief of psychiatry at Montefiore Medical Center, both in New York City. "Most are likable, even if they present themselves as hostile." Respect is even more important, since patients put themselves in an extraordinarily vulnerable position by requesting help.

Ability to Connect

Although the bond is crucial, few training programs explicitly teach the skill of connecting to patients, says Len Bickman, professor of psychology, psychiatry and public policy at Vanderbilt University in Nashville. He is exploring ways to teach therapists-in-training how to foster this relationship. One theory he is testing: whether good therapists are naturally influential people.

Comfort with Discomfort

A good therapeutic relationship won't always be fun. "There are times when the client doesn't like the therapist—and times when the therapist doesn't like the client," says Jeremy Safran, a psychotherapy researcher at the New School University in New York City.

Challenge

Providing sympathy and attention are important, according to Irvin Yalom, professor emeritus of psychiatry at Stanford. But the therapist's most important role may be encouraging a patient to take responsibility for his or her own life. That often involves challenging the patient's perception of reality, rather than offering unconditional support.

Flexibility

Following a therapeutic method too rigidly can cause rifts in the alliance, says psychologist Marc Karver of the University of South Florida in Tampa. "If a therapist strictly follows an agenda, the client doesn't feel listened to—and then certainly won't do what the therapist says," explains Karver. More important than becoming expert in a specialized therapeutic technique, clinicians need to grow and mature as people in order to foster good alliances, Karasu believes.

The best therapeutic relationship has elements of a friendship and a working partnership, in that the pair trusts each other and is working toward a common goal. Ultimately, though, it may rely a lot on human chemistry—with all the mystery that entails. "Both are human beings, with their own unique personalities and quirks," says Safran, "and some therapists just work better with some patients."

Finding The Perfect Fit

To find the right clinician, many people get a recommendation from their regular doctor, or from friends or family. Another dependable approach is the Psychology Today Therapy Directory, a free online resource that includes personal profiles of thousands of certified therapists. A good fit between therapist and client is important, and the directory provides information that will help with an informed choice.