What Happens in Therapy?

As I commence another year of practicing counselling and psychotherapy, I feel inspired to reflect on what really happens when therapy goes well for clients.

No doubt this is also influenced by my lecturing role this semester as I work with budding therapists-in-training who will learn about eleven different paradigms of therapy in their subject. During our first class, I encouraged my students to embrace the learning journey (including associated joys, and pain!) ahead of them, with a disclaimer to remember our theories/techniques account for approximately 15% of what contributes to successful outcomes in therapy (by way of comparison, the relationship-elements between client and therapist account for 30% [1]*).

As such, when in session with clients I seek to be informed by their feedback throughout the process regarding 'the work' of therapy, and especially their experience of our 'relationship'. Interestingly, what I have found is when we explore 'what is most helpful', the majority of clients respond "you really listened to me", or "I felt understood by you" (nerdy side-note - I think [without knowing it] they mean 'understood' in terms of it's associated Greek root 'entera'- i.e. knowing someone intimately, to the depths of their guts [2]).

This was further validated during a recent session with my supervisor. We both laughed together because despite all the various evidence-based theories and techniques that we've 'mastered', we're yet to hear a client say**:

• Well done on that superbly executed values-clarifying activity (e.g. Acceptance and Commitment Therapy),

• Or 'excellent down-arrowing to explore/modify my core beliefs (e.g. Cognitive Behavioural Therapy)',

• Or 'great work thickening of my constricted life story (e.g. Narrative Therapy)',

• Or 'that was impeccable use of immediacy, helping me make contact with my real experience, leading to integration' (e.g. various humanistic approaches).

Instead (at the risk of labouring the point), the vast majority of clients say something to the effect of 'you actually listened to me and I felt understood. Thank you this helped so much!'

We do well to value what clients actually say they experience, as they understand it from their frame-of-reference when partaking in therapy (they are the client after all). Yet our experience as therapists is concurrently valid, and should not be discounted. We as therapists (hopefully) cannot deny that a therapeutic paradigm (or multiple if integrative) has guided our interactions during therapy. But maybe we should be bold and acknowledge that our clients primarily (dare I say) experience our accumulated psychological wisdom, and elegant intervention as deep listening, and being understood, which inevitably catalyzes positive change.

So all this being said, I propose that we not 'throw the baby out with the bathwater'. Instead, what might be more helpful is to reframe how we understand psychological theories and techniques, not in a reductionist sense as 'ideas' or 'tools' to manipulate clients into a state of wellbeing, but rather 'informed pathways enabling deep listening for the client's benefit'.

...

*Of course, these figures should not be interpreted independently of one another. In reality each domain of therapeutic-effect is 'interdependent, fluid...' and in 'dynamic' relationship with the others, and cannot be cleanly separated (3, see also 4).

**Though I do not deny some clients have explicitly shared having benefited from particular 'interventions', and certainly appreciate 'upskilling' (however this might be understood across the various therapeutic paradigms), I still contend that effective 'intervention' and 'upskilling' are predicated on deep listening and understanding.

(1) Norcross, J. C. (2011). Psychotherapy relationships that work: Evidence-based responsiveness (2nd ed.). Oxford University Press.

(2) Online Etymology Dictionary. (n.d.). Understand. Etymonline. https://www.etymonline.com/word/understand

(3) Hubble, M. A., Duncan, B. L., & Miller, S. D. (Eds.). (2010). The heart & soul of change: What works in therapy (2nd ed.). American Psychological Association.

(4) Norcross, & Wampold, B. E. (2018). A new therapy for each patient: Evidence‐based relationships and responsiveness. Journal of Clinical Psychology, 74(11), 1889–1906. https://doi.org/10.1002/jclp.22678