What makes therapy work?

Research has consistently shown that psychological therapy does help many people most of the time (see Duncan, Miller, Wampold, and Hubble 2010). But, interestingly, the research has solidly shown that this help is not because of the psychological technique or type of therapy chosen.  In fact all psychological approaches tested seem to work equally well. So, if it is not the psychology technique (including Gestalt therapy techniques), what makes therapy work? And does anything go?

Prominent researchers Scott Miller, Barry Duncan, Bruce Wampold, and Mark Hubble  have examined many of the studies into therapy outcomes and concluded that factors common to all therapeutic approaches support change. That is:

  • The largest source of change lies in what the client brings – their strengths, struggles, culture, preferences and events in their lives.
  • The relationship and alliance between therapist and client directly contributes to change
  • The hope and expectations of both the client and the therapist contribute to change happening
  • Specific psychological techniques contribute a very small amout to outcomes – estimates range from about 1% to 8% of the change is due to specific psychological techniques

Research has also shown that clients not therapists make the most accurate predictions of whether therapy will be successful, and that this is based on the client’s experience of their relationship with the therapist.

This means that what has the best chance of working is a therapy that supports each of these sources of change. The chance of a successful outcome is supported if:

  • Clients are asked about their opinions about the therapy, the relationship
  • The therapist is committed to collaboratively evaluating the work with their clients, and to improving their own work
  • The clients explanation of how change happens for them is activated
  • The therapist must have a explanation of how change happens, and must believe in this explanation. 
  • The therapist’s model of how change happens must be a good fit with the client
  • The therapist must have multiple techniques – if something is not working, they must be able change what they are doing

Keeping an eye on progress is also critical to the success of the therapy. People engaged in counselling with me may expect to be regularly asked with about the impact of interventions, sessions, the therapeutic relationship, and progress in general.

In light of this, if you are considering therapy with me, I encourage you to read what I have written on psychotherapy and gestalt therapy, so you may get a sense of whether my primary way of doing psychological work fits with how change happens for you.

More information about Miller and Duncan’s work can be found here.

Length of Psychological Therapy

While the outcome of psychological therapy can not be guaranteed, I use several rules of thumb to guide how long therapy may take.

 People who are more distressed usually need longer work.

  • For those people who have experienced trauma, psychotherapy is usually shorter if:
    • You were functioning ok before the trauma, and
    • You are safe now, and
    • What happened was bad, but not extremely severe
  • People who have experienced severe trauma, or who still are not safe, or who weren’t travelling that great before the trauma can expect therapy to take longer 

It also depends on you want to achieve. Deeper psychological work may take longer, and in my opinion lasting change is unlikely with fewer than 12-16 sessions. But there is no rule that says all psychological work must be completed in one go. Your goal may reflect what is realistic for now – such a return to good enough functioning. It is important to discuss what you would like to achieve with your therapist at the beginning of therapy, and at each time you pause to review the work.

 That said, research indicates that some psychological change often happens within the first 6 sessions (see Duncan, Miller, Wampold, & Hubble 2010), and if no change (however small) is occurring for you after 6 months then it is important to discuss the reasons for this with your therapist. One possible reason is that events external to the psychotherapy – such as domestic violence, drug addiction, or other life events – are important to attend to.

 Another reason might be that what has happened in your life is so severe that fast change is unlikely. Another reason may be that the therapy itself needs adjusting to a method that suits you better. Or you may have the wrong therapist. This may not be that the therapist is not competent, but instead that the match between you and the therapist may not be right.

Frequency of sessions

How often to attend psychotherapy can be a balance between an individual’s emotional need and the financial cost of psychotherapy (or other practical limitations). Also important is that effective psychological therapy often requires continuity – if there are too many gaps between sessions it can feel like starting again each time, and gains can be lost.

Here are my suggestions about how frequently to meet for psychotherapy:

  • If your need is strong, and your distress is very high  then I recommend attending psychotherapy at least weekly.
  • Weekly therapy is also often used by people engaged in long term personal growth work.
  • Fortnightly psychotherapy is useful when you would like to regularly work away at the psychological issues that concern you. Fortnightly sessions may take longer to achieve the same results as weekly, but not necessarily twice as long. What is learnt in psychotherapy needs time to take in, digest, and feed into your own change, so fortnightly sessions can work well.
  • Monthly sessions are “top-up” or maintenance counselling. This can be useful for people who have achieved significant change in their lives, and just want to keep on top of things psychologically. I do not recommend monthly psychotherapy for people starting therapy as I believe that the length of time between sessions is too long to start change happening.