The Heart and Soul of Change: Delivering What Works in Therapy Hardcover – 30 Dec 2009
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This is a gem of a book, challenging many of our dearest assumptions about psychotherapy. As Bruce Wampold sets forth in Chapter 2, for over 100 years psychotherapy has based itself on the medical model, which he boils down to the five components: 1. a disorder, complaint or problem. 2. an explanation of that disorder, complaint, problem. 3. a mechanism of change, how to fix it, that fits the general explanation. 4. based on that mechanism of change, several specific actions emerge which ought to help. 5. "Fifth, and most important, the therapeutic action [#4] is responsible for the benefits of the psychotherapy and not other factors, such as the alliance with the therapist (i.e., the decrease in symptoms was caused by [for example] prolonged exposure and not other therapeutic actions or conditions). This last component, which is referred to as "specificity", is in many ways the hallmark of medicine." (p. 51.) As Wampold shows in his "meta-analyses" (analyzing groups of psychotherapeutic research studies), specificity - the superiority of a given specific approach for specific disorders -- doesn't explain why psychotherapy works, at least for the most common psychological disorders.
(I note that, in working with Complex PTSD for over 20 years, I rather think that here and, say, in working with those with Asperger's/High Functioning Autism, that we may need to adjust "specifically" to the disorder. Not all treatments work. Believe me, I know. Disorder-specific ways of relating appear most important, along with a delicate balance of client-driven, family-driven and problem-driven approaches appear, at least in my experience, most effective. Plus, as with the basic common factors, matching different treatments and relationships to fit client goals and strengths.)
For 75 years, this position- that all genuine therapies are equally effective - has been called "the DoDo Bird Effect". This is from an incident in "Alice in Wonderland" where there's a chaotic race. At the end, the racers ask the DoDo Bird who won. The DoDo Bird answers, "Everybody has won, and all must have prizes."
(Research shows that psychotherapy is, indeed, remarkably effective, with a fairly consistent "treatment effect" of .80, meaning that 79% of people who received psychotherapy got more benefit, more healing than people who did not receive psychotherapy. What we psychotherapists do works. By the way, don't let that bit of statistics scare you; this is most definitely NOT a statistics book, and the numbers presented are translated into English, i.e., simple explanations with percentages.)
In other words, while psychotherapy is effective, the medical model isn't a good explanation for why psychotherapy works. A better explanation: the "Common Factors Model". This concentrates on factors common to all genuine psychotherapies - clients, therapists & the psychotherapeutic relationship, an effective rationale for treatment, etc.
Since common factors are common to all psychotherapies, however, they're extremely difficult to isolate. Nor is there a single universally-accepted description of common factors. Common factors also tend to come all in a whole, and with much overlapping.
But careful research has teased out many fairly specific areas. And within these areas, many factors or aspects appear to contribute to success in psychotherapy. For example, the client/therapist relationship has been hypothesized and tested in psychotherapeutic research for over 50 years, starting with Carl Rogers. And indeed, that relationship accounts for some of psychotherapy's effectiveness-- much more than specific technique or theoretical approach. Further, within that relationship, "empathy" - the therapist understanding the client's situation as the client experiences it, and the therapist communicating this understanding warmly back to the client - has consistently been shown important in making the psychotherapeutic relationship effective.
Two chapters, written by long-time "giants" in the field, are especially recommended: "Clients: The Neglected Common Factor" by Arthur Bohart & Karen Tallman and "The Therapeutic Relationship" by John Norcross. These chapters, with Wampold's chapter and the editors' "Introduction", set out strong research evidence supporting common factors, and aspects within common factors.
There are good up-to-date research summaries for important areas within psychotherapy, for example, common factors with children/teens (Chapter 11), common factors in family/couples therapy (Chapter 12) and common factors in Substance Abuse/Dependence Treatment (Chapter 13).
All these and more are real eye-openers for psychotherapists who have been fed, over the past 15 years or so, a steady, near-exclusive diet of specific treatments (almost all cognitive/behavioral) for specific disorders. It was an eye-opener for me, and I was trained primarily by several students & colleagues of Carl Rogers!
But as a psychotherapist, what I found most helpful: This book concentrates, throughout, in each chapter, on how I can put these research findings into my actual practice. This is set forth in the book's subtitle, "Delivering What Works in Therapy". And the editors state that this is the principle difference between their new 2nd edition (2010) and the first edition (1999). (Though updated research - and there's been quite a bit - is indeed welcome. It's good to know that common factors research still holds.) As the editors say, in their "Introduction" (Chapter 1), in a section headed, "Moving from What Works to Delivering What Works",
"Understanding and disseminating the science of the common, therapeutic factors - how therapy really works - can go a long way toward restoring public confidence [in psychotherapy as an effective treatment]. It does not, however, address the issue of accountability. Meeting that challenge requires a major shift in the traditional way psychotherapy has been conducted and researched. It is no longer a matter of which therapeutic approach is best. Rather, it is about showing that a treatment, conducted by a given therapist with a particular client at a specific time and place, yielded positive results." (p. 39)
"Delivering What Works" is part of all chapters, which give, in some ways, specific ideas for practice that any good clinician can use. And the book itself concludes with another editors-written chapter, "Delivering What Works".
Perhaps the "Heart and Soul"'s most important ideas come from two research results. First, "who knows what's working". Again, the research is clear: clients, not therapists, are the best judgers of what is and isn't working in therapy. The practice implications are clear: we psychotherapists must find many and individual ways to regularly, carefully and systematically get clear feedback from our clients. Second & related, "meet the client where the client is". In other words, as psychotherapists we must not only negotiate treatment goals with clients, privileging the client's understandings of their problem and their goals. We must also be flexible enough AND plural enough -- well-trained in different therapeutic approaches & relationships -- that we don't fit the client to the treatment & relationship, but rather we fit the treatment & relationship to the client, including the client's culture, gender, age, strengths, supports and preferences. Clients often come with their own style of relating and their own ideas on what will best fit them, what will work to solve their problem, to help them heal.
We psychotherapists need to better listen to our clients, carefully collecting feedback throughout therapy -- verbal and non-verbal - not only in every session, but moment-to-moment. Then we need to adjust whatever needs adjusting to "meet the clients where they are".
This is the heart and soul of psychotherapeutic change.
Read this book. Period. You and your clients will be glad you did.
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