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What Is the Future of Psychotherapy?

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Psychotherapy is, very broadly speaking, the process intended to help people use their minds to better cope with life. To say the least, it has had a rocky history. Past therapies have included: exorcism, screaming, sitting inside a pyramid shape structure, being treated like lab rats, sitting on a couch with someone ‘uhming and aahing’ for four to five years, to ‘therapists’ providing only listening, and, ehm – no therapy. 

Currently, there are more than 1000 different psychotherapy and counselling approaches or schools. With such a wide range of approaches has the ‘profession’ become more effective than the intellectual stone-age examples above? Let’s explore.

Most therapy schools claim to be ‘scientific’, to be ‘evidence-based’. If they are, why do they all achieve the same poor results? What accounts for that uniformity of dismal outcomes from such widely differing methods?

‘Dismal’? Yes, dismal. The meta-analysis, repeatedly shows that psychotherapy is around 30% effective, or 70% ineffective. The same number, 30% of people with a challenge, get better after chatting with a friend over a cup of coffee. 

Would you hire a plumber who failed 70% of the time? Or a doctor who killed 70% of their patients? Of course, not. Yet, decade after decade we continue to confirm that, at best, psychotherapy is 70% ineffective. Some approaches, (IAPT, nationwide in the UK), have been demonstrated to be 90% ineffective. That is, 90% of the time they fail and are a waste of time of money.

That is not to say that there are no effective psychotherapists; none who receive consistently great results. There are some. Alas, they are so rare that I have repeatedly heard them referred to as ‘unicorn therapists’. Personally, I know several, and they are truly amazing. 

What does that tell us? That what makes therapy effective is less to do with any school, theory or dogma, and much more to with the therapist. Indeed, the research tells us exactly that: the biggest predictor of rarely successful therapy is the quality of rapport between the therapist and the client. It could be that the school, dogma, method or approach is no more than a bit player or placebo. And since the various different types of therapy seem to make no difference with clients (up to 90% failure rate), perhaps the placebo works best not for the client, but for the therapist; giving them the belief that their ‘therapy’ is sound, despite the overwhelming evidence to the contrary. 

Perhaps there is a placebo effect for some clients. If so, it is reasonable to ask: how effective is psychotherapy compared to sugar pills or other forms of placebo?

The least potent placebos are around 15% effective and can work even when people are told that they are being given a placebo. That is better than the dismal 10% reported for IAPT efficacy. The most effective placebos are around 72% effective. Yes, you read correctly. That is, a good placebo is over twice as effective as most psychotherapy, and over seven times more efficacious than the widely reported IAPT 10% figure.

What are we to make of those figures? Could it be that psychotherapy is no more than a talking administered placebo? If there are over 1000 different therapy approaches, dogmas and methods, and they have the same lack of results, it seems that there is no, or very little, the active ingredient in the methods. If there were any powerful active ingredients in the wide range of approaches, we would have evidence that some were achieving consistently great results, regardless of the therapist using the method. Alas, there is no such evidence.

What then is going on in the rare cases where psychotherapy works? 

Placebos work by covertly using the mind to activate and harness the natural healing processes. Jerome D Frank, in his 1961 book, Persuasion in Healing, noted that psychotherapies are attempts to persuade the client to change. 

Putting three factors together may provide further insight. People who are most effective at changing the behaviour of others, such as the world’s top salespeople, are also exceptionally skilled in forming deep, meaningful, and transformative rapport. If a therapist has those skills and persuades the client that approach X will solve their problem, or make it easier to cope with, even if there is no efficacy in approach X, the placebo effect will be harnessed.

Unicorn psychotherapists, who can form an exceptional rapport with their clients, seem better able to persuade their clients to make constructive changes that enable the client to improve. Unicorns can be found practising a wide range of different techniques. That again, indicates that results come more from the therapist than the therapy style. If almost magical rapport formation skills are the basis of successful therapy, that would explain the poor results across the whole profession: therapists are not selected or evaluated on their rapport formation skills, or on their outcomes. They are, in the main, academically tick-box selected and trained. 

What other factors could account for such rarity of the rapport formation skills necessary to persuade clients to change?

Peppered throughout the literature on persuasion is a reference to credibility. What role does credibility play in psychotherapy and counselling? 

If a smoking cessation therapist has nicotine stains on their fingers, prematurely aged skin, a smoker’s voice and gets out of breath getting up to greet you, how credible would they be?  

If a client is having obesity challenges, and the therapist is just as obese, how credible are they? 

Credibility seems to be a substantial factor in both rapport formation and outcomes. A therapist who does not practice what they preach, preaches to ears, is rendered deaf by the example set. 

How many times has this scenario played out? An obese client is told by an obese therapist about the health benefits of losing weight. People learn well from examples. What will the client learn from the obese therapist? ‘The health benefits are so compelling that, I, the professional, have chosen not to heed my own advice. Please copy my example, nor my implorations.’

Early on in my career, I noticed that the clients who improved most were those who took the most self-responsibility, whichever traumas they had faced. Those who did not change took the least self-responsibility. Their problems were more blamed on external circumstances, events in the past, lack of opportunity, traumas, and other people. 

If those who took most self-responsibility were the ones improving most, and therapy is healing by persuading the client to change, the logical question was: how can I persuade clients to take more self-responsibility? 

The implied question behind that question is: could it be that therapy is mostly a process to take a person to self-responsibility? 

If so, that seemed to be the elephant in the therapy room. Why was self-responsibility not openly discussed? Why was taking people to the point of self-responsibility not taught in therapy courses? 

I quickly found out; there were no such courses: I could find no material on how to take a person to the point of self-responsibility.

That seemed, odd, in the extreme. We have known for millennia that people who take responsibility for their own results fare better than those who don’t. Every great teacher knows that students who take the most responsibility for their own learning do better than those who don’t. Why then was that not common knowledge and practice in psychotherapy?

What are the basic elements of self-responsibility in therapy, education, or indeed, any other aspect of life?

If we look at high achievers and ask some questions, the elements become clearer.

  • Would you expect any top sports performer to say: ‘I am not responsible for how I behave in my sport’?  Never.
  • Would you hear a top tennis star saying: ‘I am not responsible for what I think during a game’?  Of course not.
  • Would you expect to hear the highest performing person in – [choose a sport or field] saying: ‘I have no control over my emotions‘? No.

All such people take self-responsibility for their actions and inner life.

When therapy clients take ownership of their behaviours, feeling and thoughts, they seem to improve, whichever therapy approach is subsequently used. In fact, I found that, mostly, it doesn’t matter what approach is used once that magic moment of self-responsibility is reached. 

Over the years I refined the technique to persuade people to take self-responsibility to the point where it can be achieved in less than 30 minutes, sometimes as few as 20. For most clients, only one session is required for them to solve their problem, assuming they do not have long-standing, severe, or complex, harmful mental behaviour patterns.

When I was conducting the research for the book, Self-responsibility Therapy, I asked many health care professionals: what percentage of your clients, come to you for help, for problems, which they have caused themselves? 

The answers ranged from 65%–90%. That is, almost all expert health professionals believe that most clients (unknowingly) are the cause of most of their own problems. 

With medical professionals seeing the consequences of people not taking self-responsibility, one would think that psychotherapists of all kinds would note the same phenomenon. When I shared it with them, did they? Not many. A large number of therapists, it turns out, are resistant to the idea.

There are several motives for that resistance. Here are a few, expressed in the present tense because the motives seem current and widespread. 

  • Shockingly, many people in the mental health field treat their clients as victims and reinforce and condone their clients’ victimhood, thus perpetuating it.
  • Some therapists are politically motivated, and use their clients to justify their political stance: ‘The system creates victims and no amount of self-responsibility is going to help them.’
  • Other ‘professionals’ seem less than ethical, and appear to want to create dependent clients, to maximise their income. 

Still, others seem to need to be needed, and the idea that a client could heal themselves by taking self-responsibility was deeply threatening their ego and their wallet. 

Almost all psychotherapists use methods that sound plausible but are based on untested, and untestable theories. That is, the claims made by many psychotherapy schools can neither be verified nor falsified; they are unscientific. 

If psychotherapy is to become a credible profession and move beyond its current 70%–90% failure rates it must become more scientific. Theories and approaches must be testable.

Cards on the table time. SRT, Self-responsibility Therapy has not yet been scientifically tested and is practised, so far, only by the people I have taught to use it. It contrasts with other approaches that are testable. Indeed, every aspect of SRT lends itself to testing, and any researchers reading this are welcome to contact me to do so.

We can test the levels of self-responsibility of the therapist, and compare that to outcomes. Why is that useful? If the credibility of the therapist is important, we would expect to see therapists who take self-responsibility, who example self-responsibility, being more effective than those who don’t.

We can test the levels of self-responsibility of the therapist, and compare those to the level that their clients adopt. 

We can assess the levels of self-responsibility in the client, before, during and after therapy, and assess the outcomes against those changes. We can test… 

In fact, almost all of the processes and approaches of SRT can be scientifically tested, for efficacy. Do we have that data? Not yet. 

What we do have is a therapy system and model that can be verified or falsified. It can be scientifically examined, and thus, improved and refined.

Here are some of the SRT hypotheses that could (and should!) be tested by researchers.

For those new to research methods, H0 (null hypothesis, or H zero) means the proposition put forward proves to have no effect and is not true. H1 is hypothesis 1, H2 is hypothesis 2 and so on.

  • H0: When clients increase their levels of self-responsibility it has no impact on therapeutic outcomes. 
  • H1: When clients increase their levels of self-responsibility it has a significant impact on therapeutic outcomes.
  • H2: Therapists with higher levels self-responsibility achieve better client outcomes than therapists with lower levels of self-responsibility. 
  • H3: Clients move more towards full self-responsibility when they are placed with therapists who have higher levels of self-responsibility than those clients who work with therapists with low levels of self-responsibility.
  • H4: Clients who adopt the highest levels of self-responsibility stay problem-free for longer than those who adopt low levels of self-responsibility. 
  • H5: Therapists who demonstrate the manifestation of self-responsibility in a given area of life, (such as being of a healthy weight), are perceived as more credible and thus are more effective in persuading clients to take self-responsibility in that given area.
  • H6: Clients who… you have the idea.

If you want to know more about SRT, if you want answers to the obvious questions:

  • How do I get my clients to the point of self-responsibility?
  • What processes or systems take people to the point of self-responsibility?
  • How can I get clients to the point of self-responsibility, quickly, systematically, and reliably?

What is the future of psychotherapy? In the wake of increasing public awareness of how ineffective it is, and of the conflict-of-interest motives of many therapists, unless psychotherapy addresses the elephant in the room, in a scientific way, the word ‘psychotherapy’ will become a word of derision. Its meaning will be further tarnished to the point of having its efficacy compared to that of a cat flap on a submarine. 

Even the unicorn therapists, those rare rapport masters who seem to be able to help almost all of their clients, may have to change their moniker to something less derogatory.

Professor Nigel MacLennan runs the performance coaching practice PsyPerform.


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