The Tragic Truth
Only one third of therapists help clients with positive growth in therapy. One third do damage to clients and the final third create no change for the client. It is appalling to know that two thirds of my fellow colleagues in the field end up doing harm or nothing for their clients. What separates the top one third of supershrinks?
This was a burning question I had all throughout grad school. Every time I asked a professor what they thought, I never seemed to be able to get a straight answer. I got something more along the lines of, “What does it say about you that you want to become a better therapist?” It was only helpful the first 4 times I answered that question.
I searched and searched until one of my favorite teachers sent me an article called On Becoming A Better Therapist by Barry Duncan. The article clearly lays out what makes a therapist “Effective” and the results may surprise you.
A study was conducted that polled over 5,000 therapists from different cultures and helping fields. The client’s perceived outcome had nothing with the therapist’s education, type of therapy used, or even years of experience! I’m not so motivated to get my doctorate anymore. So what in the world was contributing to the positive outcomes in therapy?
The Best Outcome
“The therapeutic alliance is probably best
conceptualized as an all-encompassing
framework for psychotherapy—it
transcends any specific therapist
behaviour and is a property of all
aspects of providing services” Hatcher
& Barends, 2006).
What factors contributed to this alliance between both client and therapist? An Article was written by Magaet Mccoy Lynch titled Factors Influencing Successful Psychotherapy Outcomes In it, she claims there are 5 main factors that influence a positive therapeutic outcome with clients and therapists. These are; therapist’s genuineness within the helping relationship, unconditional positive regard, empathy, shared agreement on goals in therapy and the ability to integrate humor in the relationship.
1. Therapist’s genuineness within the helping relationship
The famous humanistic psychologist Carl Rogers stressed the importance of the therapist to “freely and deeply” be himself in session. This means the therapist is congruent with his thoughts feelings and behaviors. This goes against the grain of what most people vision a therapist as.
The old frame is that the therapist was more like a snobby expert on the client’s life. Hollywood’s portrayal of a real life therapist is drastically different than the real thing. Therapists can show their genuineness with self disclosure and honest responses. The clinician must be aware and have insight into him or herself.
Supervision is vital when it comes to creating and maintaining this objective approach with clients. The therapist can ask for feedback from colleagues or a supervisor to see if they are being “real”. This characteristic fosters trust in the therapeutic relationship. A sure way to create distance between the therapist and the client is when the therapist acts as if they are somehow above or better than the client.
2. Unconditional positive regard
This aspect is all about not judging and just accepting the client for who they are. Many people come into therapy with the worry that they will somehow be judged by the therapist. Ensuring that the client is in a safe place bolsters this positive regard.
One aspect of my work that tends to tarnish this aspect is labeling and diagnosis. Diagnosing a client is important to be able to label what it going on, but a therapist should never identify the “Whole” person with their diagnosis. Humans are complex beings and limiting who they are does more harm than good in the therapeutic relationship.
This is a fundamental skill that all therapists should posses. Therapists that are able to completely put themselves in the shoes of their clients can have a more accurate depiction of who they are and what feelings arise when they go through difficulties.
An accurate empathetic understanding of the client’s awareness of his own experience is crucial to the helping relationship. Having high levels of empathy says to the client, “I understand you and where you are coming from. Your experience matters.”
4. Shared agreement on goals in therapy
Our emotions are in place to keep us the same and tell us that change is scary. Goal setting is often neglected in therapy. It is important to set goals because it measures objectively whether or not the client is making process. The therapist can ask the client how he or she feels, but unless they are clearly defining their growth then the therapist can never truly know.
Resistance often arises when the therapist and client goals are different. Some therapist may think they know what is best for the client, but ultimately great therapist listen to what the client wants and guide them in that direction.
Think of your own life. Have you ever been told that you “have” to do something? The joy of the activity is taken away and you lose motivation to do it. Therapeutic goals work the same way. When therapists transfer their own agenda onto the client, it creates a disconnect.
5. Integrate humor in the relationship
How many psychotherapists does it take to change a lightbulb?
Just one, so long as the light bulb *wants* to change.
Getting the client to laugh at their situation is a great re-frame. It subtly communicates that everything is going to be alright. Laughing with someone strengthens your bond with them and eases tension and seriousness that is all too common in therapy. When a therapist is humorous it tells the client that he is a normal person. Laughing with my clients about our situations reminds me that life doesn’t always need to be so damn hard.
“If we couldn’t laugh we would all go insane.”
Below are some questions you can ask yourself see if you possess the five traits necessary to be a good therapist.
1. Can I give the client the freedom to be who they are?
2. Can I be separate from the client and not foster a dependent relationship?
3. Can I step into the client’s private world so deeply that I lose all desire to evaluate or judge it?
4. Can I receive this client as he is? Can I accept him or her completely and communicate this acceptance?
5. Can I possess a non-judgmental attitude when dealing with this client?
6. Can I meet this individual as a person who is becoming, or will I be bound by his past or my past?
How Am I Doing?
Another article was written by Scott Miller, Mark Huble And Barry Duncan The Secrets of Supershrinks: Pathways to Clinical Excellence It supplements the first article I talked about above.
The article states that, “Who provides treatment is a much more important determinant of success than what treatment approach is provided.”(P.4) They found the same 1/3 ratio of therapist that do harm, good, or nothing at all. They also found that most of the “Good” therapist all did something very similar that the others did not.
They asked for feedback on how they were doing. That is it! It seems so simple, but knowing a lot of other therapist I can clearly see how some would just assume that they are doing a great job.
Therapist that used each session as an opportunity for feeback and learning showed vast improvements when compared to their counterparts. What is disturbing is that the least effective therapists rated themselves as most effective.
Miller and others found that when therapists used immediate feedback, their therapeutic outcome increased by 65%!
There has been substantial evidence that deliberate practice by people in fields yield the best growth. Professional sports players, gamers and many other fields all use deliberate practice to become better at what they do. Why would therapists be any different?
Duncan, Miller and Huble came up with a form that therapists can use with clients when looking for feedback. I use this form with my clients and it generates a productive conversation centered around what I am doing well and what I can improve on.
It is extremely difficult to know who to choose when looking for a therapist. Use this article and the video below to get a clearer understanding of what makes a good therapist and who can help you with your challenges in life.