Therapy Effectiveness? It’s the Relationship, Stupid

Most of the reasons for therapy’s success are simply unknown. This should keep therapists humble. The biggest factor which therapists can influence at all is the quality of the relationship. The relationship may be experienced as healing, even when therapy doesn’t measure up as “effective” at removing problems.

There has recently been an explosion of research on the outcomes of psychotherapy, investigating what factors may contribute to good outcomes, and no less importantly, to bad outcomes. But when you ask most therapists what, at the end of the day, they feel really helps those clients who are helped, most will answer that it is something to do with the relationship.

This post is made up largely of my reactions to material shared by Dr John C. Norcross, in his lecture at the recent Warsaw conference “Integration in Psychotherapy, How to Make it Work?”. Norcross is the editor of Psychotherapy Relationships That Work , the result of meta-analyses of psychotherapy research and literature carried out by a ‘task force’ from the American Psychological Association. A new edition of the book is upcoming, using up to the minute quantitative studies, but it seems as if the general drift of the results is the same.

The meta-analysis appears to show clearly that effective therapy does not have anything much to do with the therapeutic school or techniques used, and has more to do with the strength and nature of the relationship which builds up between therapist and client. These results seem to fly in the face of received wisdom from Evidence Based Practice, which serves in effect to fund those therapies which are most easily measured. (See “The Politics of Psychotherapy Research: Survival of the Measurable”.) It seems to me that the results which favour one practice over another must all be working within the small segment of the “therapy success pie”, which belongs to treatment method (around 8%), ignoring the other 92%.

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Most of the reasons for therapy’s success are simply unknown. This should keep therapists humble. After unknown factors, come ‘patient factors’, together accounting for 70% of the success pie. Next come therapy relationship, treatment method, and individual therapist factors. The relationship, according to the meta-analysis results, comes out at 12% — also not a stunning percentage, but the largest over which the therapist has any influence. It also seems to me that within the “client” and “unknown” factors are areas, such as availability of social support, and practical issues, which a good therapist should be listening to and working with.

Funnily enough, while the Person Centred tradition explicitly focuses on the relationship rather than techniques, on people rather than problems, it seems that Person Centred therapists are not any better at ‘delivering the goods’ than their colleagues who are problem-focused. In a study measuring the importance of empathy — the core of the Person Centred approach — Cognitive Behavioural therapists (who theoretically do not set much store by empathy as an ‘active ingredient’ of therapy) actually offered their clients more of it!

Does that mean that ‘shopping’ for a therapeutic theory that seems to fit your needs is a largely pointless activity, or that as a would-be therapist it would be better to ignore theory and go for an entirely pragmatic approach?

I would argue that there is a lot of sense in a therapist choosing a school in which to train. It is something like having your roots in a culture, choosing a school which suits your personality and skills, and therefore will bring out the best work you can do. Likewise, when choosing a therapist, if you have the opportunity to do so, choosing a school with a similar style to your own (more or less ‘touchy-feely’, ‘problem-solving’, etc.) might well make therapy a ‘culturally’ smoother experience. But as we all know, individuals within a culture vary wildly, and it is not because someone says they are excellent at building relationships, that you will necessarily “click” with them. And that click or not-click may be not just something to shrug off as your personal reaction, but something that will concretely affect the fruitfulness of your therapy.

After training within a certain way of seeing the world and a certain set of practices, it does not seem helpful for a therapist to cling to them too hard. After all, clients may well not share that worldview. A certain openness and inter-cultural competence is needed. And there is a danger that pragmatism, effectiveness and research results themselves may become a theory which inserts itself between therapists and their clients. For example, Michael Lambert in a lecture at the same conference recommended eliciting formal feedback after every session in order to keep close to the client’s needs. I can imagine some clients might find this opportunity to give feedback very helpful, and for others I can imagine that being asked to complete a detailed questionnaire at the end of each session could feel quite unempathic on the part of the therapist. For those in the midst of a crisis, for example, the shift in register necessary to complete the task could be counter-productive.

Does the importance of ‘client factors’ mean that there are some clients who are just not going to get any benefit out of therapy, and if these clients could be identified through research, do therapists then have ethical grounds for turning these people away? (For example, in research mentioned by Michael Lambert, there seems to be a large correlation between progress in the first few sessions and eventual ‘success’.)

Looking at my own clinical experience, I would say that if a client comes to me with a lifetime of abuse and trauma, they are most unlikely to tick any “progress boxes” within the first six sessions, and maybe their presenting problems will never go away. But during the course of a long therapy relationship, they might experience other benefits which are meaningful to them and not reducible to removal of their symptoms. The 200th session, although statistically barely effective, may not be an instance of the therapist financially exploiting the client, but an instance of a client getting what they need, maybe just to continue functioning as they are. The relationship can be valuable not only as a road to ‘therapy effectiveness’, but as a value in itself.

I think a valuing of people in themselves, including those who are never going to ‘make the most’ of therapy, or never ‘get better’, is what the therapy endeavour is all about.

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