By Dr. Allen Frances
There are three consistent research findings that should make a world of difference to therapists and to the people they treat.
First, psychotherapy works at least as well as drugs for most mild to moderate problems and, all things being equal, should be used first.Second, a good relationship is much more important in promoting good outcome than the specific psychotherapy techniques that are used.Third, there is a very high placebo response rate for all sorts of milder psychiatric and medical problems. This is partly a time effect- people come for help at particularly bad times in there lives and are likely to improve with time even if nothing is done. But placebo response also reflects the magical power of hope and expectation. And the effect is not just psychological- the body often actually responds to placebo just as it would responded to active medication.
These three findings add up to one crucial conclusion- the major focus of effective therapy should be to establish a powerfully healing relationship and to inspire hope. Specific techniques help when they enhance the primary focus on the relationship, they hurt when they distract from it.
The paradox is that therapists are increasingly schooled in specific techniques to the detriment of learning how to heal. The reason is clear- it is easy to manualize technique, hard to teach great healing. I have, therefore, asked a great healer, Fanny Marell, a Swedish social worker and licensed psychotherapist, to share some of her secrets.
Ms Marell writes: "Many therapists worry so much about assessing symptoms, performing techniques, and filling out forms that they miss the wonderful vibrancy of a strong therapeutic relationship.
Thinking I can help someone just by asking about concerns, troubles, and symptoms is like thinking that I can drive a car solely by looking in the rearview mirror. Dreams, hopes, and abilities are seen out of the front window of the car and help us together to navigate the road ahead. Where are we going? Which roads will you choose and why? It surely will not be the same roads I would take - we are different- we have to find your own best direction.
If we focus only on troubles and diagnosis, we lose the advantage of capitalizing on the person's strengths and resources. If I am to help someone overcome symptoms, change behaviors, and climb out of difficult situations, I need to emphasize also all the positives he brings to the situation. Therapy without conversations about strengths and hopes is not real therapy. And often most important: Does the patient have a sense of humor? Laugh together! Be human. No one wants a perfect therapist. It is neither credible nor human.
Symptom checklists and diagnoses play a role but don't give me no understanding of how this person / patient understands his world and her troubles. And don't drown in manuals, missing the person while applying the technique.
People come to me discouraged and overwhelmed- their hopes and dreams abandoned. Early in our time together, I ask many detailed questions about how they would like life to change. What would you do during the day? Where would you live? What would your relationship to your family be like? What would you do in your spare time? How kind of social circle wood you have? By getting detailed descriptions I get concrete goals (eg I want to go to school, I want to argue less with my parents, spend more time with friends).
Almost always, working with the family is useful; sometimes it is absolutely necessary. What would be a good life for your child? How would it affect you?
Sometimes are dreams are big, perhaps even too extravagant; sometimes they are small and and perhaps too cautious. But dreams always become more realistic and realizable when they are expressed. Sharing a dream and making it a treatment goal helps the person make a bigger investment in the treatment, and to take more responsibility for it. He becomes the driver and the therapist may sit in the back seat".
Because my first conversation is not just about symptoms and troubles, we start off on a basis of realistic hope and avoid a negative spiral dominate only by troubles. Problems have to be faced, but from a position of strength, not despair and helplessness.
Having a rounded view of the person's problems and strengths enriches the therapeutic contact and creates a strong alliance.
Thanks, Ms Marell, for terrific advice. Some of the best natural therapists I have known have been ruined by psychotherapy training- becoming so preoccupied learning and implementing technique that they lost the healing warmth of their personalities.
Therapy should always be an exciting adventure- an intense meeting of hearts and minds. You can't learn to be an effective therapist by reading a manual and applying it mechanically.
I would tell therapists I supervised never to apply what we discussed to their next session with the patient, lest they would always be a week behind. Therapy should be informed by technique, but not stultified by it.
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