12. How effective is psychotherapy?

By Tom O'Connell

Just how effective is psychotherapy? Dr. Scott Miller, speaking to therapists at the Cape Cod Institute, highlighted the importance of conversational relationships (discourses) between therapists and clients.

At sessions sponsored by Albert Einstein College of Medicine, he said discourses emphasizing "psychopathology" (the disease process) tend to diminish effectiveness. Instead, he recommends "discourses that honor and respect the client." And he asserts that "discourses which control, with an emphasis on the therapist" are less effective. He recommends "working with" the client.

He is also critical of "discourses which exclude" through the use of "special language" that the client is unlikely to understand. Instead, he encourages "inclusive language." He closed the session with a quote from Madeleine L'Engle: "The joy of unity is greater than any disorder within..."

Dr. Miller, who is director of the Brief Therapy Training Consortium in Chicago, made some powerful statements in an article published in Networker, with co-authors Mark Hubble and Barry Duncan: "Given the clear demonstrations from research that there is little appreciable difference in outcome among the various therapy models, it is puzzling that they remain the centerpiece of so much graduate professional training. How can something that makes so little difference continue to dominate professional discussion?"

In the same article, he asserts, "The most influential contributor to change is the client, not the therapy, not the technique, not the therapist, but the client. The sheer impact of their contribution when compared to other factors serves as a powerful reminder that however famous the therapist or dazzling the procedure, no change is likely to occur without the client's involvement."

Backing up his message with solid information, he referred to an in-depth study  on treating anxiety and depression, "the two most common mental health complaints." The study concluded that "self-help approaches worked about as well as treatments conducted by therapists." This information will not be news to the millions of people who have done substantial healing through 12 Step Programs of addiction recovery.  

Dr. Miller's thrust reminds me of a study by an eminent British psychologist, Hans Eysenck, to assess the value of psychoanalytic psychotherapy. Here is the description from  the Harvard Guide to Modern Psychiatry: "Eysenck's critique (1965) suggested that the effects of therapeutic intervention on patients differed little from normal life experience without treatment. He reported that roughly a third of patients improved, another third got worse, and another third showed little or no change."

Does this prove that therapy is useless and ineffective? In baseball, a hitter who bats over .300 is considered a hero. But such findings are thought-provoking. Today, many people combine various therapies with self-help group participation, and how helpful this is to their mental health only the individuals involved can explain. Yet too much dependence on a therapist may be a substitute for resolving one's own problems. The same holds true for dependence on various medications, although when someone is suicidal who can deny the prescription of mood-altering chemicals?

In the long haul though, healing needs to come from within, regardless of what catalyst we use to get there. That's why I recommend the 12 Step spiritual approach to healing. Through mutual help, members of support groups learn to deal with their inner landscapes and move beyond destructive addiction and self-defeating dependencies.

For those who do use therapists, Dr. Scott Miller emphasizes four factors: 1)Therapeutic technique..."Whatever model is employed, most therapeutic procedures prepare clients to take some action to help themselves."  2) Expectancy and placebo..."Technique matters no more than the 'placebo effect,' the increased hope and positive expectation for change that clients experience simply from making their way into treatment....an emphasis on possibilities and a belief that therapy can work will likely counteract demoralization, mobilize hope, and advance improvement." 3) Therapeutic relationships..."This is a far more critical factor than either therapeutic technique or expectancy. Clients who are motivated, engaged and connected with the therapist in a common endeavor will benefit the most from therapy....A positive bond results when the therapist is empathic, genuine and respectful." 4) Client factors:..."The client is actually the single most potent factor...The quality of a client's participation in treatment, his or her perceptions of the therapist and what the therapist is doing, determine whether any treatment will work."

Concluding, Miller says, "At the heart of the four factors that characterize all good therapy is the desire and the capacity for forming helpful and healing bonds with troubled people who have, for the time being, lost their way and need some directional signals back to their own best selves...it is our clients and the relationship with our clients that comprises the real substance of our clinical work."

So what's therapy about? And healing? It's all about relating, isn't it?

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