Why Does Therapy Work?
Psychotherapy specifically, and the whole structure of teaching people how to be happier more broadly, is a bit of an unusual process if you think about it. Two people enter a space. They talk, listen, paint, dance, close their eyes, or whatever else for some time. And then somehow one, and often both, of them ends up feeling better.
The overwhelming majority of studies have found that psychotherapy helps patients, and some have found that psychotherapy is as effective for the treatment of depression as medication while avoiding problematic side effects and potentially having a lower relapse rate after treatment. There’s evidence suggesting that Cognitive Behavioral Therapy is particularly effective when it comes to treating depression and anxiety disorders, but there’s not conclusive evidence that one form of therapy is better than another.
On the flip side, only a few of the studies demonstrating therapy’s effectiveness provide evidence without bias, and there’s a lot of publication bias in terms of what makes it into research journals. There are even some studies that have found psychotherapy to be indistinguishable from placebo when controlling for the size of the study, duration of therapy, and use of real patients rather than subjects who had been solicited for the study.
Let’s take it on both faith and reasonably good evidence that therapy “works,” that people can grow and change over time, and that psychotherapy changes how clients use their brains in meaningful ways. How does it work then, and how can we get better at helping people learn and grow?
Well, the dirty secret of the helping professions is that we’re not entirely sure.
There are a lot of good theories, but in a somewhat bizarre twist therapeutic outcome doesn’t seem to be affected by how experienced the therapist is, or whether they are a student or professional. There’s even research showing young college students with no training or experience in psychotherapy being more effective than trained professionals under specific circumstances.
This flies in the face of everything we think we know about how teaching and learning works. If therapy has a clear mechanism of action, if there’s something the therapist is doing, broadly speaking, that’s changing the client in some way, shouldn’t an experienced therapist be more effective than a completely inexperienced one? What could possibly be happening that is not improved by years of training?
The question of how we can improve therapeutic outcomes can serve as a useful proxy for a much broader question set of questions: How can we help people change in lasting ways? How can we help them remove problematic behaviors, and install positive ones in the neural structure of the brain? What really matters here?
One thing has been consistently shown to affect therapeutic outcome:
The strength of the alliance established between therapist and client.
The therapeutic alliance refers to the bond built between therapist and client. It frames treatment as a collaborative relationship that both parties buy into, while committing to shared goals and holding mutual positive regard. In plain English, a strong therapeutic alliance is formed when therapist and client are on the same page, and basically like each other. Further validating the research that decouples experience from outcome, more experienced therapists don’t necessarily form stronger alliances with their clients. Regardless of experience, empathy appears to be a key factor in the formation of a strong alliance and therapeutic outcomes more generally.
This continues to create more questions than answers. Why wouldn’t more experienced therapists be better at forming strong alliances? Or be better at empathetic relating more generally? At the furthest extreme, is it possible that many of the elaborate systems we’ve created over 100+ years provide little practical value beyond the act of sharing and being with an empathetic listener that you feel is on your side?
Having both seen a therapist and talked to empathetic friends, I can say from personal experience that it certainly feels like “something different” is going on during therapy. And there are specific practices, like Eye Movement Desensitization and Reprocessing (EMDR), that I’ve found particularly helpful. But that could be as much a function of set and setting as anything else.
To exit research and enter opinion for a moment, my experience is that there’s something unique about the therapeutic space created between a thoughtful clinician and willing client. This experience isn’t unique to therapy - it’s absolutely possible to have a therapeutic moment with a friend - but therapy provides a unique opportunity for a concentrated dose of these moments.
Is that just empathy? I don’t know. But to me the experience of feeling felt, as Dr. Dan Siegel likes to put it, is the foundation of most any therapeutic interaction.