When it comes to therapy, YOU are the secret sauce
In a 50-year review of the research about what leads to successful outcomes in therapy, one variable bested the rest: You. It’s you! Greater than therapists' techniques, greater than their knowing head nod and “tell me more about that" demeanor. More influential than the degrees hanging on their walls and throw pillows on their sofas. YOU rose above all else as the key ingredient to your healing.
“The quality of the patient’s participation...[emerges] as the most important determinant of outcome.” Orlinksky, Ronnestad and Willutzki (2004)
The “quality of the patient’s participation”...okay, but what does that even mean? Let's break it down. When we talk about participation in therapy we are talking about showing up open to the process and willing to engage in the tasks of psychotherapy. Those tasks may differ from one approach to the next, but they typically involve talking, making space for self-reflection, being present in the moment, and taking a collaborative approach to sessions rather than an approach that depends on the therapist to steer the time together. The literature shows that clients who engage with their creativity and a sense of agency get a lot out of their therapy. It also shows that those who connect their therapy to their day-to-day life, whether by sharing with trusted friends, reflecting on previous sessions or preparing for upcoming appointments, had more positive outcomes.
High-quality participation doesn’t mean blindly following the therapist's suggestions and recommendations. Rather, taking what one finds most helpful from sessions and folding it into previously existing ways of being in the world in a practical way, seems to help most.
So does this mean that if I have struggled to see my desired outcomes in therapy, it’s my fault?
It’s true that historically clients have often been blamed for their lack of progress in therapy. This is a misuse of the literature about the essential role clients play. Digging a little deeper into the literature offers some more contextual answers that just make sense to us.
First, not all humans respond well to the typical therapy environment or typical therapy behaviors. For example, much of therapy still exists in the realm of talking and sitting. There are lovely exceptions to that, and those more somatic models are likely a better fit for many folks for whom talking just does not hit right. “Typical therapy solutions do not work equally well in mobilizing the self-healing capacities of all clients.” (Bohart and Tallman)
Second, we know that clients who have more extensive functional impairments don’t typically experience easy progress in therapy. It is essential for these folks to have a more collaborative treatment approach, a clear understanding of what is going on diagnostically, access to information about what is evidenced-based given their current status, and a treatment plan that is customized to how they work best in therapy and what types of interventions are most helpful. Often when someone is really struggling in their functioning, this is not an easy resource to find. Clarity and expertise often feel like the golden ticket.
We know this isn’t great news. But we think it is important to share nonetheless and to be honest about those challenges. We see clients like this from time to time and I am so inspired by the self dedication it takes to find what is truly supportive to them.
Third, it is common for therapy models and therapists to underestimate the impact of your surroundings. We call that your ecological circumstances. Therapy focuses much of the time on helping clients change from the inside out. We adjust inner factors to create an outward experiential change. But it isn’t a secret our environments affect us in the other direction. Therapists we know have grown in this area significantly in the past 10 years, but we still have work to do in recognizing and understanding the impacts of life circumstances, exploitative systems, biases of others, etc. in honest, humble and non-stigmatizing ways. Especially white, cis, hetero, thin, able-bodied therapists. There…we said it.
And for all the therapists reading along wondering, “What’s my job again?” I know you probably aren’t having an identity crisis based on this blog post, but I do know that I (Autumn) sat with this article and wanted to reflect about the ways I could engage with clients. I want to draw out their inner healing wisdom, support when I need to, and then mostly make sure I am getting out of their way.
Here’s what the research points to regarding clinical implications:
1. Therapists need to lean into clients’ resources and strengths throughout sessions, not just in a wrap-up at the end of their appointments.
2. Therapists need to check their biases and narratives about “unmotivated” clients. There is no such thing as an unmotivated client. Clients are making moment by moment choices that have a positive rationale even if this isn’t yet understood by the therapist.
3. As therapists, we benefit from significant and ongoing training around reflection, listening and doing our own emotional work in our own therapy when we are struggling to be present.
One other factoid in the research that stuck with me is that clinicians who stay silent or refuse to give advice can hinder clients’ progress (Conrad & Auckenthaler, 2007 and Von Below & Werbart, 2007). I think we have come a long way from “blank screen” therapists on whom clients can project any and all of their beliefs. We are now allowed to be people while being therapists. In fact, many clients demand it.
Still, I am often very reluctant to ever give advice or fill silence. This research has me sitting with whether or not I am doing that because it’s how I was trained, or if I am truly meeting the moment with my clients and using my clinical discernment more actively.
All of this talk around how we can show up best for clients reminds me of another article I recently enjoyed about the power of therapeutic presence. Maybe my next blog post.
- Autumn Starks, LCSW (about)
Founder and Psychotherapist, Starks Therapy Group
Google “Clients: The neglected common factor, Bohart and Tallman” for the PDF of the article that inspired and is referenced in this Secret Sauces Series.
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