Damon Ashworth Psychology

Tag: life

The Top 20 Movies of My Lifetime (10-1)
Looking at the American Film Institute’s 100 Greatest American Films of All Time list that came out in 1998, most films are super old. For example, ‘Citizen Kane’ (1941) ranked at #1, ‘Casablanca’ (1942) ranked at #2, ‘The Godfather’ (1972) ranked at #3, ‘Gone With the Wind’ (1939) ranked at #4 and ‘Lawrence of Arabia’ (1962) ranked at #5.

I loved ‘The Godfather’ but fell asleep in ‘Casablanca’ and ‘Lawrence of Arabia’. However, I agree with ‘Gone With the Wind’ being up there, especially seeing that it is the highest-grossing movie of all time, adjusted for inflation. I also need to see ‘Citizen Kane’ before making any judgments on it, but I tend to like modern movies more than most movie critics.

Out of the entire top 100, only 8 came out after 1985, the year that I was born:
- Schindler’s List (1993) — #9
- The Silence of the Lambs (1991) — #65
- Forrest Gump (1994) — #71
- Dances with Wolves (1990) — #75
- Platoon (1986) — #83
- Fargo (1996) — #84
- Goodfellas (1990) — #94
- Pulp Fiction (1994) — #95
None of these movies made my top 20 countdown either, so clearly, the movie critics and I don’t always see eye to eye.

In 2008, the AFI came out with their 10th-anniversary list, and ‘Raging Bull’ (1980) and ‘Singing in the Rain (1952) had replaced ‘Gone With the Wind’ and ‘Lawrence of Arabia’ in the top 5. The top 100 choices were still predominantly old movies, with only 14 movies released after 1985:
- Schindler’s List — #8
- The Lord of the Rings: The Fellowship of the Ring (2001) — #50
- Unforgiven (1992) — #68
- Saving Private Ryan (1998) — #71
- The Shawshank Redemption (1994) — #72
- The Silence of the Lambs — #74
- Forrest Gump — #76
- Titanic (1997) — #83
- Platoon — #86
- The Sixth Sense (1999) — #89
- Goodfellas — #92
- Pulp Fiction — #94
- Do the Right Thing (1989) — #96
- Toy Story (1995) — #99
There were two movies from my top 20 countdown in the list, which makes me feel a little better. Interestingly, ‘Fargo’ and ‘Dances With Wolves’ became less admired over time and dropped out of the list. On the other hand, ‘Unforgiven’, ‘The Shawshank Redemption, ‘Titanic’, ‘Do the Right Thing’ and ‘Toy Story’ became more admired since 1998 and made the 10th-anniversary list after missing the first countdown. I hope they come out with another list in 2018 to mark the 20th anniversary and look forward to seeing what they include.

After seeing a movie these days, I get interested in knowing what movie critics thought of the movie. Rotten tomatoes is a great website that accumulates all of the professional movie critics reviews on a particular movie and gives an aggregate score out of 100% based on how many reviews are positive for the film. Here are the Tomatometer ratings for numbers 20 through to 11 in my top 20 movies of my lifetime countdown:

#20 — The Conjuring (2013) — 86%

#19 — The Castle (1999) — 88%

#18 — Midnight in Paris (2011) — 93%

#17 — Groundhog Day (1993) — 96%

#16 — Donnie Darko (2001) — 86%

#15 — Before Sunrise (1995) — 100%

#14 — The Truman Show (1998) — 94%

#13 — The Sixth Sense (1999) — 85%

#12 — Inglourious Basterds (2009) — 89%

#11 — Good Will Hunting (1997) — 97%

To qualify for this countdown, I need to have seen the movie, enjoyed it, and found that it had an emotional impact on me somehow. Here is my top 10, with their IMDb star rating and their rotten tomatoes Tomatometer score:

# 10 — Eternal Sunshine of the Spotless Mind (2004) — IMDb star rating: 8.3/10, rotten tomatoes Tomatometer = 93%

The tagline for the movie says it all: “You can erase someone from your mind. But, getting them out of your heart is another story.” A strange but touching movie about a couple who keep going to a memory clinic to try and erase the memories of someone they love in the hope that they can move forward with their lives. However, without even knowing why, something keeps bringing them back together. Seeing that Jim Carrey now has 2 movies in my top 20, it seems that he should have played serious roles more often.

# 9 — Requiem for a Dream (2000) — IMDb star rating: 8.4/10, rotten tomatoes Tomatometer = 78%

I feel like this should be shown to anyone who thinks that drugs are cool, especially teenagers. I haven’t spoken to anyone who has watched this movie and hasn’t had a strong visceral reaction to it, either positive or negative. It may be why it has the lowest Tomatometer score out of any movie on my countdown. The director Darren Aronofsky achieved more critical acclaim for his 2010 movie ‘Black Swan’, which was also quite unsettling to watch, but this one had more of an impact on me.

# 8 — The Lion King (1994) — IMDb star rating: 8.5/10, rotten tomatoes Tomatometer = 92%

Drawing inspiration from William Shakespeare’s ‘Hamlet’, I was obsessed with ‘The Lion King’ when I was younger, and it first came out. The story and the music were amazing, and I bought the soundtrack on CD and the movie on VHS as soon as they were released. It’s heartbreaking, uplifting and hilarious, and my favourite Disney cartoon of all time.

# 7 — Back to the Future (1985) — IMDb star rating: 8.5/10, rotten tomatoes Tomatometer = 96%

A movie that nearly wasn’t made. When the writer and director first sent the script of ‘Back to the Future’ around to the Hollywood studios, nobody wanted to touch it. The studios knocked it back about 50 times, and it wasn’t until the director had success with another movie that it was greenlit for production. A movie about a hero who befriends a weird old scientist who takes him back into the past where he has to evade his biological mother, who is crushing on him, seems like a weird premise for a movie. However, it became a massive box office hit with two sequels and a huge fan base even to this day. Time travel, when done well, is another truly magical aspect of going to the movies. Being able to learn about where you have come from and what your parents were like when younger is another really fascinating thing that we will never be able to see unless they captured it on video.

# 6 — The Usual Suspects (1995) — IMDb star rating: 8.6/10, rotten tomatoes Tomatometer = 88%

“The smartest trick the devil ever pulled was convincing the world he didn’t exist”. A very clever movie by Bryan Singer and the best in his career, in my opinion, although some of his X-Men movies were good too. But, like ‘The Sixth Sense’, it also has a twist at the end that completely changes the viewing experience of the movie. Who is Keyser Söze? It would be best to watch to find out and then see it a second time to see what signs you missed.

# 5 — The Matrix (1999) — IMDb star rating: 8.7/10, rotten tomatoes Tomatometer = 87%

I remember the marketing campaign in Australia when it first came out — “What is the Matrix?” It gave nothing away about the movie and yet made me feel like I had to watch it or I would miss out. Once I saw it, it blew my mind. Probably the most original action movie that I have ever seen. It has been copied and emulated many times since, so it probably doesn’t seem groundbreaking these days, but the bullet-dodging and slow-motion sequences were amazing. I wish they didn’t bring out the sequels, as they took away some magic from the first movie. If you had a choice, would you take the red pill and be exposed to the truth, or would you take the blue pill and live in ignorant bliss?

# 4 — Inception (2010) — IMDb rating: 8.7/10, rotten tomatoes Tomatometer = 86%

Another very creative and inventive premise with great visual effects. I think Christopher Nolan is a great director, and he likes to get his audiences to think. The difference between reality and dreams is something that has come up a few times on this list. Still, Inception takes it to a whole new level, saying that we can implant an idea into the subconscious mind of someone else during their sleep to impact their behaviour when they are awake. The way that time is altered at the different levels of dreams is great. Also, the spinning top at the movie’s end leaves the interpretation of what happened wide open.

# 3 — Fight Club (1999) — IMDb star rating: 8.8/10, rotten tomatoes Tomatometer = 79%

David Fincher is another of my favourite directors. He has an especially great knack for turning good books into excellent films, including this, ‘Gone Girl’ and ‘Girl With a Dragon Tattoo’. The antisocial, antimaterialistic and anarchistic nature of this film really appealed to me at the time. It made me question what I thought I knew about what was important in this world. It didn’t make me want to start a fight club or punch anyone, but to live a life that was more autonomous and genuine. The surprise ending is almost as good as ‘The Sixth Sense’ and ‘The Usual Suspects’ too.

# 2 — The Dark Knight (2008) — IMDb star rating: 9.0/10, rotten tomatoes Tomatometer = 94%

This movie is epic in scale and is really all about Heath Ledger as the Joker. I was concerned that he wouldn’t size up to Jack Nicholson’s version, but he surpassed it in every way possible and stole the scene whenever he was on the screen. It is one of the greatest performances of all time, in my opinion, and he truly deserved the Oscar for the role, especially considering the toll that it seemed to take on his emotional and psychological well-being. It was annoying that the character of Rachel changed from Katie Holmes in ‘Batman Begins’ to Maggie Gyllenhaal. Apart from that, this is the greatest Batman movie of all time, and the car chase scene through the tunnel is also the best chase scene of all time.

# 1 — The Shawshank Redemption (1994) — IMDb star rating: 9.2/10, rotten tomatoes Tomatometer = 91%

The highest-rated movie of all time on IMDb and, therefore, well-deserving of the #1 movie on my list. Interestingly, this wasn’t a big hit when it first came out but continued to build an audience over time once released for home movie consumption. Morgan Freeman is always great in movies, especially when he plays the narrator, but this one is his best. The ending is exceptionally uplifting, too and would give hope to even the most cynical viewer out there.

Thanks for checking out my list. Do let me know if you agree or disagree with any of these titles in the comments section below or if you think another title should have made the countdown!

Dr Damon Ashworth

Clinical Psychologist
June 28, 2017
The Top 20 Movies of My Lifetime (20-11)
A list like this will always be subjective, and I don’t expect others to agree with it. However, I still think it is worth highlighting the movies that have significantly impacted my life and why this is the case. If you believe something amazing is missing from the list, please let me know in the comments section below.

I was born in 1985, so the movies on the list have been released in 1985 or later. All films on the list also have to be movies:
- that I have personally watched,
- that I have personally enjoyed, and
- that have emotionally impacted me in some way.
WHY MOVIES ARE IMPORTANT

Unfortunately, the longer I practise psychotherapy, the more I can see its limitations. Over time, it has become easier for me to look at the traps that people consistently fall into and the logical steps people need to overcome these difficulties.

However, people are not just logical creatures. They have emotional reactions to things based on their past experiences and beliefs. Therefore, for long-term change to occur, we need to connect and bring about change emotionally.

This is where stories become relevant. Whether through a good fiction book or a great movie, stories can connect with us emotionally and move us more than a rational argument ever could. Without further ado, here is my list, ranked based on their IMDb star rating:

# 20: The Conjuring (2013) — IMDb star rating: 7.5/10

Quite simply, I have never been more scared watching a horror movie in the cinema than this one. I locked my arms between the armrests so that I didn’t jump too much, and the amount of sweat I produced by the end of the movie was intense. The sequel is almost as good, but the scene where the mother wakes up and thinks that her kids are playing a clap-clap version of hide and seek is genuinely terrifying. James Wan is a master of his craft, and his supernatural stuff is much better than the Saw series.

I was tempted to include ‘Wake in Fright’, the Australian outback horror, instead of this as it has a higher IMDb rating and was an uncomfortable watch. However, the success of a scary movie needs to be about how scary it is, and therefore ‘The Conjuring’ is the perfect way to kickstart the list.

# 19: The Castle (1997) — IMDb star rating: 7.7/10

My only Australian movie on the list. I was thinking about my most quoted movie of all time, and this is a close battle with ‘Anchorman: The Legend of Ron Burgundy’ and ‘Happy Gilmore’, however ‘The Castle’ has a higher star rating and gets the nod for being an Aussie film. From “tell ’em to get stuffed” to “the vibe” to “the serenity” to “he’s an ideas man” to “we could talk for hours” and “I dug another hole”, The Castle is a truly classic Australian film. For anyone who hasn’t seen it yet, please do yourself a favour and check it out. Truly knee-slapping fun.

# 18: Midnight in Paris (2011) — IMDb star rating: 7.7/10

It is the best Woody Allen film by far, in my opinion. Many people might say ‘Manhattan’ or ‘Annie Hall’ or even ‘Hannah and Her Sisters’ may be better, but I tend to prefer the movies that Woody actually doesn’t appear in himself. When Owen Wilson’s character gets to go back in time and meet F. Scott Fitzgerald and Ernest Hemingway and Salvador Dali and Pablo Picasso, this is movie magic at its finest. Plus, Marion Cotillard as Adriana is magical too. I’d escape Rachel McAdams as Inez for her any day.

# 17: Groundhog Day (1993) — IMDb star rating: 8.0/10

Just brilliant, in my opinion, and the best Bill Murray film by far. What would you do if you were stuck living the same day over and over again in a town that you didn’t want to be in? The main character, Phil, first tries to take advantage of others. He then commits crimes, tries to kill himself, learns skills, helps others and finally finds true love. Another great example of movies teaching us something using a method that couldn’t possibly happen in real life.

# 16: Donnie Darko (2001) — IMDb star rating: 8.1/10

This is an example of the right movie at the right time. I was experiencing a lot of suicidal ideation when this movie came out in 2001, and the main song from the movie ‘Mad World’ by Gary Jules connected with me in a way that not much else did. It seems to be the closest depiction I’ve seen of ‘The Catcher in the Rye’, my favourite novel at the time by the author J.D. Salinger. It was a dark time for me, and Donnie Darko really helped me to feel that I wasn’t alone in my struggle. It looked to be the start of a promising career by director Richard Kelly, but he doesn’t seem to have done much since 2009’s ‘The Box’.

# 15: Before Sunrise (1995) — IMDb star rating: 8.1/10

I enjoyed all three films in this trilogy, but the first one was my favourite by far. Two strangers, randomly meeting each other on a train in a foreign land, spending the night together wandering around the streets of Vienna and developing a powerful connection in the process. I also really liked ‘Boyhood’ and ‘Dazed and Confused’ from Linklater, but ‘Before Sunrise’ takes the cake for why I love travelling and meeting new people and saying yes to spontaneous experiences.

# 14: The Truman Show (1998) — IMDb star rating: 8.1/10

This and ‘EdTV’ were really at the forefront of the reality TV movement that has taken over commercial TV these days. ‘The Truman Show’ is a much better movie, however. Who hasn’t imagined themselves as the main character in a story? I know I have. What if everything was just a set-up to create conflict and tension for the millions of viewers out there? Would you like this, knowing that you are likely to be safe and cared about for the rest of your life? Or would you rather break free and experience an authentic and genuine life experience and give yourself a chance of finding real love and happiness? We all have a choice between what is expected of us and what we would really like to do.

# 13: The Sixth Sense (1999) — IMDb star rating: 8.1/10

Unfortunately, one of my friends spoiled the twist at the end of this movie before I saw it, so I’ll never get to experience watching it without knowing what was actually happening. However, I still loved it, which is a true credit to how great the movie is. Early on, I would have listed M. Night Shyamalan as one of my favourite directors. How far his and Haley Joel Osment’s career fell after this gives you an indication of how fickle Hollywood can be, but it was nice to see the director return to some form with the recent ‘Split’. Hopefully, his upcoming sequel to ‘Unbreakable’ will be good too. At its essence, ‘The Sixth Sense’ is an exploration of the topic of grief. I wonder what mediums think of this movie and its most famous quote, “I see dead people”?

# 12: Inglourious Basterds (2009) — IMDb star rating: 8.3/10

The best Tarantino movie, in my opinion. The tension he can create through dialogue is amazing, especially with the extended scene at the beginning of the film and the even more extended scene in the basement bar. Tarantino is a movie nerd through and through, and many people will say that ‘Pulp Fiction’ is his masterpiece, but this is better than that in many ways for me. Christoph Waltz was amazing, and getting to revise history in a way that leads to Hitler being shot in the face by a machine gun would have no doubt be satisfying to many. However, it also shows that big budgets and lots of action can never make up for poor dialogue when building up suspense. It’s a pity ‘The Hateful Eight’ was so bad. Here’s hoping that Mr Tarantino makes a return to form with his next film.

# 11: Good Will Hunting (1997) — IMDb star rating: 8.3/10

My favourite movie on therapy and the benefits that it can bring. It’s great to see Robin Williams in some of his more serious roles, too, including this one, ‘What Dreams May Come’ and ‘Dead Poets Society’. The scene where Robin Williams character Sean says to Matt Damon’s character Will that it’s not his fault for the prior abuses that have taken place in his life is compelling, as it finally leads to a breaking down of the barriers that Will puts up to defend himself. This is all too obvious with many of the clients that I see who have had abusive pasts. Many of them continue to treat themselves as harshly as their perpetrators once treated them. It is heartbreaking to see it time and time again, and I wish that they too could truly grasp and genuinely feel that they were not responsible for the abuses that they have suffered.

Stay tuned for #10 through to #1…
June 28, 2017
Do You Want To Be Deliberately Better?

“Good company in a journey makes the way seem shorter.” — Izaak Walton

It was 2016 when I first decided to take on the challenge of being accountable to myself. I later wrote this blog to take responsibility for my actions in an open, transparent way, do what I said I was going to do, and “practice what I preach.”

For me, as a Psychologist, becoming deliberately better is all about evidence-based living. It is about engaging as much as possible in thinking patterns and behaviours that research has shown to lead to a happier, more satisfying, higher quality of life.

The following were five key areas that I planned to focus on for 2016, with the idea of it having positive flow-on effects for my long-term psychological well-being in 2017 and beyond.

The best part is that just by stating these objectives where they can be seen publicly, my desire to be consistent and faithful to my word did seem to help me to stay more committed to achieving these goals:

1. Tuning in rather than tuning out

Too often in Western Culture, we spend all of our day “doing”, rushing around and completing tasks. We do not spend enough time “being”, simply living in the moment with whatever we are experiencing.

People tune out of their experiences by distracting themselves with watching too much TV, spending too much time on social media, or surfing the internet. They could also smoke cigarettes or use drugs, drink too much caffeine or alcohol, eat junk food, and keep busy with too much work. Some of these strategies are successful in blocking out what we feel in the short term. However, suppose you never listen to the signals that your body sends you. In that case, they will only amplify in intensity over time until, eventually, we will have no choice but to notice the message given.

Formal mindfulness practice is the best way to get the most benefits from tuning in and just being. Mindfulness practice consists of maintaining our attention on whatever is occurring at the moment in an open, curious, accepting, patient, non-judging, and non-striving way. I recommend learning guided meditations first and then practising on your own if you’d prefer once you have figured out the various forms of meditation and how they help you. I would recommend a few free apps if you are interested in learning these skills: Smiling Mind, Calm, and Headspace.

Once you have learned the basics of mindfulness, it becomes a lot easier to also engage in informal mindfulness practice, where you apply these same mindfulness principles in whatever task you do throughout the day. By tuning in through Mindfulness, the benefits include reduced stress, pain and anxiety, improved sleep and mood. There is also a higher capacity to soothe yourself when distressed and a reduced risk of a future depressive episode.

2. Turning towards my values rather than away from fear

I regularly bring up values with my clients. It is for a good reason. The way I see it, there are two primary motivators in life. We can either be motivated to move towards what is important to us (our values) or move away from the things we fear.

As first pointed out to me in Daniel Kahneman’s book ‘Thinking, Fast and Slow’, most people are predisposed towards being risk-averse or more motivated by what they may lose rather than what they could gain. As a result, most people play it safe, stay in their comfort zone, try not to change things too much, and don’t take any chances, even if the potential gains outweigh the potential losses.

Most people need at least a 2:1 ratio of things being likely to turn out well before taking a risk, and some people will never take a chance unless a positive outcome can be 100% guaranteed (which isn’t a risk at all). For example, the risk of dying in a plane crash or being eaten by a shark are minuscule. However, I’ve met several people who choose not to fly or swim in the ocean because of these fears. My question to these individuals is, “What do you lose by not taking this risk?” The chance for fun? Excitement? Adventure? Considering that these values are all important to me, I’d allow myself to feel the fear, sit with it, and take the risk so that I can live a more vibrant, enjoyable and meaningful life.

All of the most successful treatments for anxiety involve exposure to the feared stimuli as an essential part of the treatment. By facing our fears, stress can be reduced and no longer cause significant distress or functional impairment. It is uncomfortable but worth it in the pursuit of a goal that is consistent with your values. By living in line with your values and not those of others, you are more likely to feel energised, motivated and satisfied with where you are at and where you are headed.

3. Maintaining an ideal work/life balance

One of the biggest traps that I see with my clients is putting off enjoyment today until some designated time in the future (e.g. once I finish uni, once I get a job, once I pay off the house, once I’ve saved a certain amount). What tends to happen in the meantime is that they dedicate most of their life to study and work and saving, and postpone looking after themselves or having fun, exercising, engaging in hobbies, being creative, learning a new skill, travelling, and socialising with others.

The Grant Study, which began in 1938 with 268 Harvard undergraduate men, is still running and collecting data over 77 years later. Across all of this data, they found that one thing was the most significant predictor of health and happiness later in life: relationship warmth. Individuals in loving relationships with close families and good friends outside of their partner were the most satisfied with life. But, of course, it wasn’t just about the number of friends or family either. It was about having those quality relationships where you knew you could depend on the other person when you needed them the most.

Making more money did correlate with overall happiness and health outcomes, but individuals with higher relationship warmth also tended to make more money. Therefore, it is crucial to spend time with others and put energy into cultivating positive relationships. Given this data, socialising with those we care about should never be seen as a waste of time.

4. Writing things down rather than keeping things in

Planning and reviewing are essential for minimising stress and ensuring that we stay on track with our goals. In the excellent book ‘Getting Things Done’ by David Allen, he recommends both a daily review and a weekly review. In these, you can go through everything and process it into an all-encompassing management system. By having everything where it is supposed to be, and either filed away or waiting to be done at a particular time and place, it is meant to ensure that our head is as straightforward as possible. In addition, it can enable us to focus on whatever is most important to us at the moment (e.g. the task that we are doing).

I recommend that my clients quickly jot down whatever is incomplete or still to be done at the end of the workday. It is crucial to follow this with a quick plan on when you can address this task and the first step that you would take. It shouldn’t take any longer than 5 minutes a day and can help make sure that you can switch off from work once you are at home. For individuals who don’t sleep well due to a racing mind, doing this same process with anything on their mind two hours before they go to bed will also reduce their likelihood of being up all night thinking.

The crucial step is to write down when you will do it (and what the first action is), rather than just making a to-do list. The Zeigarnik effect shows that our brains will continue to remind us of something incomplete until we have done it or have a plan to do it. But, surprisingly, once we have a plan in a place that we won’t forget, our brains treat the task as already being done, and the result is a less busy mind, less stress and more energy. So even if you want to finish painting the house but won’t have time until your annual leave in 3 months, write it down. Or create a someday/maybe file, and put it in there.

5. Developing a growth rather than a fixed mindset

In her book ‘Mindset: The New Psychology of Success’ Carol Dweck has identified a more crucial concept towards academic and occupational success than intelligence.

Individuals with a fixed mindset believe most of their traits, including intelligence and personality, are fixed or unchangeable. Because of this, they tend to view successes as evidence that they are amazing and mistakes as evidence that they are horrible or not good enough. Unfortunately, this means that whether they win or lose carries massive consequences because their identity is on the line with everything they do in many ways. If they experience a setback, they won’t try to learn from it or improve because what’s the point? They aren’t good enough, so why bother trying. They’ll also give up more quickly when things become challenging and demanding.

Conversely, the individuals with a growth mindset will view their performance on a task as just that — their performance, and not an indication of how smart or capable they are. Instead, they see setbacks as chances to learn and grow and improve their skills in the future. Because of this, they are happier to challenge themselves and persevere through difficulties. They are also much more compassionate and understanding when they make a mistake, rather than self-critical like the individuals with a fixed mindset.

Fortunately, you can teach a growth mindset. By praising behaviour and effort (“You tried so hard”) rather than characteristics (“You are so smart”) and viewing mistakes as an essential part of the learning process, growth mindset training increases motivation, resiliency and achievement. So even if you don’t naturally look at things in this way, it’s never too late to learn and grow.

Dr Damon Ashworth

Clinical Psychologist

December 31, 2016
What Do Clients Find Most Helpful About Therapy?
When clients first begin their therapy journey, they often ask to be taught specific skills to help them achieve their particular goals.

Clients believe that if they can be taught these skills, they will overcome their difficulties or the problems that led to them entering therapy. They will then have no subsequent complications or need for additional treatment in the future.

Cognitive Behavioural Therapy (CBT) is a short-term treatment that clients can easily understand. CBT is based on the premise that all difficulties arise from unhelpful cognitions (beliefs, expectations, assumptions, rules and thoughts) and unhelpful behaviours. Therefore, CBT aims to help clients see that their cognitions and behaviours are unhelpful and tries to teach them skills that can help them 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 believe that if a client can have more helpful cognitions and behaviours, they will have significantly improved psychological health and overall well-being. I’m just not sure if I agree that the process required to get to this outcome is the same as what many CBT clinicians would believe. For example, focus on distorted cognitions has been negatively correlated with overall outcomes in cognitive therapy for depression studies (Castonguay, Goldfield, Wiser, Raue, & Hayes, 1996).

What leads to improvements in treatment?

The 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 resources and readiness to change (40% of overall outcome variance)
- The therapeutic relationship (30% of total outcome variance)
- The expectations about the treatment and therapy (15% of global outcome variance)
- The specific model of therapy (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 compared to what they were looking for at the beginning of their treatment.

Irvin Yalom’s excellent and informative book ‘The Theory and Practice of Group Psychotherapy’ goes into detail about a study he conducted with his colleagues that examined the most important 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 regarding how valuable 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: recognising 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 only rated each of the 60 individual items concerning how helpful it had been.

When looking at these categories, giving advice or suggestions about what to do is often not found to be a beneficial element of the therapy process, even though this is precisely what most of the clients are initially looking for. Instead, it is far more critical to develop a more in-depth knowledge of themselves, their inner 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.

All 20 clients had been in therapy an average of 16 months and had finished or were about to complete their treatment. These items were about group therapy, so the most critical factors for change in individual treatment may be different. However, even with individual treatment, Yalom believes that the relationship heals in the end.

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.

Suppose you have ever wanted to discover and learn more about yourself, accept yourself more, express yourself better or develop more trust in others. In that case, longer-term psychological therapy may be just what you need!

Dr Damon Ashworth

Clinical Psychologist
June 30, 2016