When clients first begin their therapy journey, they often ask to be taught specific skills that are going to help them achieve their specific goals.
They believe that if they can be taught these skills, they will be able to overcome their difficulties, or the problems that led to them entering therapy, and they will have no subsequent difficulties or need for additional therapy going forward.
Cognitive Behavioural Therapy (CBT) is a short-term treatment that clients can easily understand. It is based on the premise that all difficulties arise from unhelpful cognitions (beliefs, expectations, assumptions, rules and thoughts) and unhelpful behaviours. CBT aims to help clients see that their cognitions and behaviours are unhelpful, and tries to teach them skills that can help them to replace these unhelpful cognitions and behaviours with more helpful ones. If this is achieved, the assumption is that clients will change and therefore improve.
I do believe that if a client is able to have more helpful cognitions and behaviours then they will have significantly improved psychological health and overall well-being. I’m just not sure if I agree that the process that is required to get to this outcome is the same as what many CBT clinicians would believe. In fact, focus on distorted cognitions has actually been shown to have a negative correlation with overall outcomes in cognitive therapy for depression studies (Castonguay, Goldfield, Wiser, Raue, & Hayes, 1996).
What actually leads to improvements across treatment?
My previous article “What Leads to Optimal Outcomes in Therapy?” answers this question in detail and shows that the outcome is dependent upon (Hubble & Miller, 2004):
- The life circumstances of the client, their personal resources and readiness to change (40% of overall outcome variance)
- The therapeutic relationship (30% of overall outcome variance)
- The expectations about the treatment and therapy (15% of overall outcome variance)
- The specific model of treatment (15% of overall outcome variance)
For cognitive therapy for depression, both therapeutic alliance and the emotional involvement of the patient predicted the reductions in symptom severity across the treatment (Castonguay et al., 1996). Many therapists are now aware of these findings, but clients are generally not.
What do clients view to be the most valuable elements of therapy once they have improved?
By the end of treatment, especially if it is a successful outcome, clients tend to have a much different outlook on what they think are the most valuable aspects of therapy when compared to what they were looking for at the beginning of their treatment.
In Irvin Yalom’s excellent and informative book ‘The Theory and Practice of Group Psychotherapy’, he goes into detail about a study that he conducted with his colleagues that examined the most helpful therapeutic factors, as identified by 20 successful long-term group therapy clients. They gave each client 60 cards, which consisted of five items across each of the 12 categories of therapeutic factors, and asked them to sort them in terms of how helpful these items were across their treatment.
The 12 categories, from least helpful to most helpful were:
12. Identification: trying to be like others
11. Guidance: being given advice or suggestions about what to do
10. Family reenactment: developing a greater understanding of earlier family experiences
9. Altruism: seeing the benefits of helping others
8. Installation of hope: knowing that others with similar problems have improved
7. Universality: realising that others have similar experiences and problems
6. Existential factors: recognizing that pain, isolation, injustice and death are part of life
5. Interpersonal output: learning about how to relate to and get along with others
4. Self-understanding: learning more about thoughts, feelings, the self, and their origins
3. Cohesiveness: being understood, accepted and connected with a sense of belonging
2. Catharsis: expressing feelings and getting things out in the open
1. Interpersonal input: learning more about our impression and impact on others
The clients were unaware of the different categories, and simply rated each of the 60 individual items in relation to how helpful it had been to them.
What becomes apparent when looking at these categories is that giving advice or suggestions about what to do is often not found to be a very helpful element of the therapy process, even though this is exactly what most of the clients are initially looking for. What is far more important is the client developing a deeper knowledge of themselves, their internal world, and how they relate to and are perceived by others in interpersonal situations.
The top 10 items that the clients rated as most helpful were (Yalom & Leszcz, 2005):
10. Feeling more trustful of groups and of other people.
9. Seeing that others could reveal embarrassing things and take other risks and benefit from it helped me to do the same.
8. Learning how I come across to others.
7. Learning that I must take ultimate responsibility for the way I live my life no matter how much guidance and support I get from others.
6. Expressing negative and/or positive feelings toward another member.
5. The group’s teaching me about the type of impression I make on others.
4. Learning how to express my feelings.
3. Other members honestly telling me what they think of me.
2. Being able to say what is bothering me instead of holding it in.
1. Discovering and accepting previously unknown or unacceptable parts of myself.
Each of the 20 clients that made up these survey results had been in therapy for an average of 16 months, and were either about to finish their treatment or had recently done so. Obviously these items were in relation to group therapy, so the most important factors for change across treatment in individual therapy may be different. However, even with individual therapy, Yalom believes that in the end, it is the relationship that heals.
For more information, feel free to check out Chapter 4 in ‘The Theory and Practice of Group Psychotherapy’ by Irvin Yalom and Molyn Leszcz (2005), or any of the other studies out there that look into the outcomes or therapeutic factors involved in change across psychological treatment.
If you have ever wanted to discover and learn more about yourself, accept yourself more, express yourself better, take greater responsibility for your life, challenge yourself and develop more trust in others, a longer-term psychological therapy may be just what you need!
Dr Damon Ashworth