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Why do most approaches to psychotherapy achieve the same success rate, 30% or less, despite vast differences in the methods used?
There are thousands of different types of psychotherapies. Most claim to be different in some way, yet all seem to have the same failure rate. Yes, the failure rate is around, or greater than, 70%.
Let’s put that in to perspective. Would you use a physician whose failure rate was 70%? Would you commission a plumber or electrician or carpenter who failed to deliver more than 70% of the time? Of course not.
Do most people know how ineffective psychotherapy is? No. Have professional psychotherapy bodies announced to the world the reality of the high failure rate? No.
‘Why most psychotherapies are equally ineffective’ is an explanation that is long overdue.
What are the overall outcome figures? At best 30% (ish) of people with mental health challenges improve on their own, 30% (ish) stay the same or get worse, and 30% (ish) respond to psychotherapy of some kind. The placebo effect success rate ranges from being around 15% up to 72% effective.
Are we saying that placebos can be more effective than psychotherapy? Yes, by a long way. Typically the placebo effect has around 30% success rate. What does that mean? That a typical placebo is as effective as psychotherapy, and the best placebos are more than twice as effective.
Questions flow thick and fast from that awareness: is psychotherapy just a placebo? Is psychotherapy a method-based, rather than pill-based placebo?
Recent evidence suggests that psychological approaches may be less effective than a placebo. Research in to IAPT outcomes (Improved Access to Psychological Therapies – in the UK) found that only around 10% of people using psychological services showed any improvement.
Is psychotherapy so ineffective because it is no more than a placebo, and, a particularly ineffective placebo?
Other research has demonstrated that the biggest predictor of psychotherapy outcomes is the quality of the rapport between the therapist and client. That has huge implications. It suggests that method matters little, and rapport matters hugely. Is that the reason for the ineffectiveness of psychotherapy? Despite the huge number of different methods, are they irrelevant, and rapport is king?
A quick reminder: the success rate across the board of psychotherapies is embarrassingly low (10%–30%). If rapport is the key factor accounting for the few successes, what specifically creates a good rapport?
It should be said that there are some therapists who are hugely effective, over and over again. What are they doing that others are not? What is on the good therapists’ ‘must do’ list?
Some on that list are obvious, such as communication skills. Being highly articulate or eloquent seems much less important than having excellent listening skills and high degrees of empathy. Clients for whom therapy works express that they felt understood, listened to, and supported. Some say that for them, therapy was the first time they ever felt fully understood. That too, indicates that rapport is king and method plays only a bit part.
Many people report that their best friends are the only people who really understand them. If that is the case, you might expect to find that some people, when they have a mental health challenge, turn to their best friends. Indeed, that turns out to be the case: many people solve their problems after a chat with a friend over coffee.
Can a chin-wag with a friend really be as effective as formal psychotherapy? Yes, the evidence indicates exactly that. Indeed, it may be more effective, because the friend has more detailed knowledge of the person, and is more available to provide ongoing support.
Is that another reason that psychotherapies are so ineffective? Is it that they don’t have access to the range and accuracy of information that a close friend will have acquired?
Is psychotherapy, no more than a substitute for a good friend? Are therapists paid friends? If friends are so good for each other, what are they doing that would otherwise happen in psychotherapy? Friends, mostly, have no formal psychotherapy training. That means they are forced to focus on the person, and not on any technique.
Could it be that psychotherapists, focus on the techniques at the expense of their person-focus? If a deep rapport already exists with friends, is that why they are so good, so therapeutic for each other? Or, is it that, despite no formal training, friends have real life experience, and they already know the person being helped? Is that combination, why friends are as, or more effective than, PhD-educated psychologists?
Could it be that the person providing therapy is more effective than any method as long as that same person somehow possesses emotional support skills and provides the following?
- Respect for the other person’s views
- Simplicity and straight forwardness
- Avoidance of any pretensions or poses
- Able to put themselves in the other’s shoes
- A serious serving of humanity and sensitivity
If techniques are less important, for what reason are so many psychotherapy books and courses filled with all sorts techniques? Could it be that being in possession of formal methods serves to give therapists confidence?
Is it that if the therapist believes their techniques work, that such belief is picked up by the person receiving help? Is the client ‘infected’ with that belief, and as a result, the technique works (in 30% of cases)?
If so, that seems to mean that the techniques are placebos. We know from studies into the effectiveness of placebos, that the more the person giving the placebo believes it is real, the better it works.
Is psychological training no more than equipping the trainee therapist with a range of placebos? Is the training made more effective if the would-be therapist believes that the techniques work?
If that is the case, it seems that psychotherapy is a double placebo; because the therapist thinks the method-based placebo is real they are able to dispense the placebo with maximum credibility. The client then believes in a positive outcome, because the therapist does, and both self-fulfil that belief.
Could it be that the 10%–30% psychotherapy success rate can be attributed to a combination of rapport and the placebo effect?
It seems odd to rule out therapy techniques as a success factor. Yet, the question remains: if the methods have any efficacy, why are friends as effective as trained therapists?
Could it be that since most friends have have had to develop their own real-life, real-world techniques to deal with their own life problems, that they are able to bring a life-time of methods to help themselves and others?
How many of those techniques help? Could it be that the number of techniques that actually make a difference is so small that most people learn them or figure them out for themselves?
Perhaps friends, through life-experience, are able to provide the key components of psychotherapy. If so, what are some of those components?
- Rapport, as we have already stated
- Being interested, genuine and understanding
- Enabling a safe space to express emotions
- Providing support and reassurance
- Creating an atmosphere of positive expectation and hope
Are those six components central to all psychotherapies? Yes. Are those the behaviours of good friends? Yes. Do good friends have a head-start on any therapist because of their knowledge of the person they are helping and the depth of their rapport? Yes.
Going full circle, if rapport is the biggest predictor of a successful outcome, and friends have a deeper rapport, does it make sense that they would be as effective as formally trained therapists? Yes.
To answer the implied question at the start, why most psychotherapies are equally ineffective, could it be because they are all, unknowingly, doing the same things? Are they all placing too much emphasis on theory and technique, at the expense of the factors that make a real difference?
Professor Nigel MacLennan runs the leadership coaching practice PsyPerform and is a visiting professor at the University of Bolton.