Why does therapy work? How does change actually happen? These are questions I often find myself asking. I am currently undertaking my PhD and I keep coming back to these questions. If I state that I believe in the power of therapy, it could be considered a biased statement certainly. Yet, I am very grateful to have found and experienced a therapist I clicked with who has been so relationally reparative for me over the past seven years. I am grateful, as I have also had the unfortunate experience of therapy, which was not reparative, in fact in one case it was harmful to me. Apart from my own experiences as a client, I also have the honour and privilege to witness my clients doing their own courageous work, which leads to change week in and week out. Despite all of this, I still can’t help but wonder, what is happening when change occurs for someone who has the courage to engage in therapy?
Many clients often enter therapy hoping for relief from distress, greater self-understanding or a different way of relating to themselves, others and the world around them. Despite more than a century of theorising and research, there remains no single explanation for how therapeutic change occurs. As humans, our brains are designed to strive for, and love, single explanations, or silver bullets so to speak. The brain interprets certainty and knowing as safety. However, no matter how much research is conducted or books are written or therapy hours are undertaken, there is no silver bullet. Notice what it is like to even read those words, there is no silver bullet. That can leave us feeling unsettled at best and fearful and anxious at worst!
What has emerged over time as people ask and ask again about change is a recognition that change is a complex process involving the interaction of therapeutic relationships, client autonomy, life circumstances and experiences that unfold both within and outside the therapy room. Historically, different schools of psychotherapy have proposed different mechanisms of change. Within psychoanalysis, for example, change is often understood as occurring through the development of insight into unconscious conflicts and relational patterns. Behavioural approaches, such as Applied Behaviour Analysis, propose that change occurs through learning, reinforcement and behavioural modification. Cognitive approaches, such as Cognitive Behavioural therapy, emphasise the identification and restructuring of maladaptive beliefs and assumptions. Humanistic and person-centred approaches, such as Person Centred Therapy, highlight the importance of empathic understanding, congruence and unconditional positive regard as the conditions through which growth could emerge in a relationship. This is to name only a few as there are hundreds of different types of therapy.
Although these approaches differ in their theoretical explanations, psychotherapy outcome research has increasingly suggested that successful therapies share a number of common factors. The so-called ‘Dodo Bird Verdict’, first articulated by Saul Rosenzweig, an American psychologist and therapist, observed that many different therapeutic approaches produce broadly comparable outcomes. This has been explored extensively since and has pointed research more towards the common factors that work in therapy, as opposed to what therapy works best.
One of the most influential findings from this body of research concerns the importance of the therapeutic relationship. Across modalities, the quality of the alliance between therapist and client consistently emerges as one of the strongest predictors of outcome. Clients who experience their therapist as empathic, collaborative, trustworthy and genuinely engaged tend to experience better outcomes than those who do not. The relationship itself appears to function as more than a context for ‘doing’ therapy, it is often a vehicle of change in its own right.
This relational emphasis has been strongly articulated in psychotherapy research, which increasingly supports a relationally orientated approach to therapy with evidence suggesting that relational processes are central to positive outcomes. Rather than viewing change as the product of techniques alone, it is apparent that change emerges through the quality of engagement between therapist and client and through the extent to which therapy responds to the unique needs, preferences and goals of each individual. Research from Pluralistic Therapy further suggests that therapeutic effectiveness may be enhanced when clients are active participants in shaping the direction of therapy. Put simply, respecting a person’s autonomy and ability to know, and share, what they find useful or not is paramount in therapy.
At the same time, psychotherapy research has consistently demonstrated that factors external to therapy also play a significant role in change. Much of the variance in therapeutic outcomes is attributable to client and extra-therapeutic factors rather than therapeutic techniques alone. Every person who attends therapy brings with them existing strengths, resources, relationships, opportunities, challenges and environments that influence their capacity for change. Yes, therapy sessions undoubtedly matter, as research finds people do better with therapy than without. However, the therapy hour occupies only a small proportion of a person’s life. A client may spend 60 minutes a week in therapy, but the remaining 10,020 minutes, to put this in perspective, are spent navigating relationships, workplaces, families, communities and internal experiences. It is within these contexts that therapeutic insights are tested and integrated.
From this perspective, therapy can be understood more as a space that supports and facilitates change. A client may recognise a longstanding pattern of self-criticism during a therapy session. However, awareness and insightful moments alone rarely transform a person’s whole world. Change begins when that awareness accompanies the person into everyday life. It emerges when they notice the critical voice during the week, pause before accepting it as truth and experiment with responding differently, for example. The therapeutic experience may initiate a new understanding but the process of change develops through repeated experiences outside the therapy room. The work in the therapy room is not isolated, rather, it is part of a whole.
This idea is reflected across several therapeutic traditions. Regardless of approach, many therapies assume that experiences outside of sessions are essential to consolidating and maintaining change. Contemporary process research supports this understanding. Studies examining therapeutic change suggest that clients often describe improvement as an accumulation of experiences over time. These experiences frequently involve applying learning from therapy to everyday situations, engaging differently in relationships, making new choices and reflecting on therapeutic conversations between sessions. Therapeutic gains, so to speak, appear to be strengthened when clients actively integrate what occurs in therapy into their daily lives.
There really is no single pathway to change because different clients benefit from different processes at different times. What has worked for me in my therapy may not work for the next person. Some individuals may change through gaining insight, others through emotional expression, behavioural experimentation, relational experiences or shifts in self-understanding or all of the above and more. In practice, therapeutic change is multifaceted.
Therapy and life outside therapy are therefore not separate domains. They exist in a reciprocal relationship. Each informs the other. Clients bring their lived experiences into therapy and therapy influences how they engage with the those experiences on a day to day basis. Most interestingly, recent research has found that a person’s willingness to change makes up for about 30 percent of therapy ‘working’. This is closely followed by a safe and strong relationship between client and therapist attributed to 15 percent of what works. The approach or type of therapy used makes up for 10 percent of the experience of change. The person of the therapist themselves makes up for seven percent of this and, finally, other and unexplained factors make up the remaining majority of change at 35 percent. Therefore, wondering how does change work in therapy may be something we never get a definitive and final silver bullet answer to. Yet, therapy can provide the conditions in which new possibilities become tangible for any person who wants to show up and experience the fullness of themselves. It is through living those possibilities that change gradually becomes part of a person’s life as result of what happens both inside and outside the therapy room.
For more information on Leo’s services, phone: 085 1300573
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web: www.leomuckley.com
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