The Treatment Model of Psychotherapy

This month’s column is based on a very interesting presenting I heard a year or so ago from Dr. Arthur C. Bohart about what actually makes therapy work. 

The traditional assumption is that a patient or client presents their problems and the therapist makes a diagnosis.  From that diagnosis, the therapist chooses what treatment to apply (medication, cognitive behavioral therapy, a Rogerian or Jungian approach, etc) to the patient’s condition.  The patient is then “fixed” by the treatment.

This is a “treatment” model of therapy.  The emphasis is on treatment techniques with specific treatments for specific disorders.  Relationship between the patient and the therapist is secondary but does serve a support function.

However studies do not support this model.  There seem to be no statistically valid differences in outcome due to different treatments being used.

Does the Therapeutic Relationship Make the Difference?

Studies show that therapist empathy only accounts for about 8% of the outcome of therapy.  There is little evidence that professional training and experience makes one a better therapist.  My own past experience in training and supervising lay therapists (volunteers with an interest in helping but with no professional education or licensing) is that they made excellent therapists, often with better outcomes than professionals with the same patient populations.

In addition, self-help studies show that the therapeutic relationship is not necessary at all.

So What Is Most Important?

If different approaches work equally well, if techniques play only a small role, if professional training is not that important, and if, in fact, therapists aren’t even needed, what conclusion does this lead us to?

The answer is that the patient or client is the most important common factor.  Client involvement is the single best predictor of outcome of psychotherapy.

So the client is an active self-healer.  The client or patient invests in the therapeutic procedures offered, thinks about the process, draws his/her own meaning from it, and creatively translates what happens in therapy into his/her own life to create change.

As I reach my 40^th anniversary since becoming a professional therapist, I can attest to the fact that this is true.  It’s like the old joke about how many psychologists it takes to change a light bulb…one, but the bulb has to want to change! 

Is it still worthwhile trying to find a therapist who offers what you want or need?  Of course, but that is because as the client or patient, that will be the only context in which you will be willing to do the work you need to do.