Sarah Panofsky

Sarah Panofsky

I am a clinical counsellor, educator, and researcher.

What Really Makes Psychotherapy Work?

What Really Makes Psychotherapy Work?

In choosing a counsellor you may be concerned about the approach or the model that they use with clients. Certain approaches have been more empirically tested, that is research has been conducted on them to see how well they work with clients, than others. Cognitive Behavioural Therapy or CBT is one of these. CBT is a structured therapy approach that works to change thoughts and behaviours to create overall client change and has become the “gold standard” in the psychotherapy field. CBT is manualized, it follows certain protocols that make it easy to standardize across different clients, making it well-suited for research and medical settings which demand standardization. CBT is taught in medical schools and referred by physicians. I agree that CBT is an effective form of psychotherapy—just not perhaps for the reasons that we assume (i.e., that there is something about CBT interventions that make it essentially effective). Rather, I have learned from Bruce Wampold and Zac Imel (2015), long-time psychotherapy researchers that there are common factors inherent in all psychotherapies that impact client outcomes.

These common factors are beautifully simple: the therapeutic relationship, agreement on the expectations of counselling, and existence of therapeutic actions.

Let’s start with the therapeutic relationship, this is the foundation of psychotherapy, and it reflects a real relationship between a therapist and client. This alliance is emotional, intimate, and genuine underscoring “the ability and willingness to be what one truly is in the relationship—to be authentic, open and honest” (Gelso & Carter, 1994, p. 297). Psychotherapy is powerful becomes it provides the client with a human connection that is empathic and caring. This connection is health promoting in and of itself, particularly for clients who have experienced chaos or disregard in social relationships. Research tells us that the stronger the relationship between counsellor and client, the better the therapy outcome, regardless of the theoretical orientation of the counsellor.

The second factor speaks to agreement on the expectations of psychotherapy and underscores the importance of hope and belief that therapy is, in fact, beneficial. When the client believes that participating in therapy will help them in coping with their problems, they build confidence that they can do what is necessary for change. In some ways this is akin to the placebo effect—what is important for creating expectations is not that a theory or treatment is validated scientifically, but that they client accepts the therapist’s explanation for their suffering and the therapeutic actions that are aligned with that explanation.

The third factor describes the specific ingredients or therapeutic actions enacted in psychotherapy. In CBT these may be worksheets on cognitive distortions or in therapy as I practice it, working in mindfulness to better understand the emotion, sensation, movement, and memory associated with a particular thought. What Wampold and Imel’s (2015) research tells us is that particular therapeutic actions alone do not create better client outcomes, simply they must be a part of the therapeutic process and that these, along with the alliance and agreement on the expectations of therapy are what fosters therapeutic change.

Every model of therapy promotes psychological well-being; the approach is less important that existence of these three factors, the therapeutic alliance, agreement on what works in therapy, and following through on therapeutic actions.

Get started on your journey, book a free consultation.

Gelso, C. J., & Carter, J. A. (1994). Components of the psychotherapy relationship: Their interaction and unfolding during treatment. Journal of counseling psychology41(3), 296.

Wampold, B. E., & Imel, Z. E. (2015). The great psychotherapy debate: The evidence for what makes psychotherapy work. Routledge.

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