First, a clarification: My post “Make my therapy plain, but with a twist” ended with the question (comment, really), “Who says there is nothing new in the world of psychotherapy?” One could easily get the impression that this referred to Dr. Allen, whose post I was discussing. It did not. In fact (as is clear in his latest post), Dr. Allen appreciates advancements in psychotherapy as much as anyone I know. I erred in not noticing the apparent implication of that closing sentence.
However, that’s not to say that sentence was thoughtless or random. In fact, it was born of frustration (call it a pet peeve) over the course of 30 years in the field, hearing statements from a range of people, including patients, students and professionals, that “all therapies are the same,” “There’s nothing new under the sun” and “It doesn’t much matter what a therapist does, patients will get better.”
New remedy on offer
I’m sure Dr. Allen is as bothered by such statements as I am. True, a variety of interventions are generally (though not always) beneficial. However, it does not follow from this that it doesn’t matter what you do. There is plentiful evidence that some interventions work better for some disorders than others (for a sampling of research supporting this statement, visit www.academyofct.org). It is also true that therapy also can cause harm (more on this, perhaps, another time).
Dr. Allen’s post reminds us that the argument about common factors versus prescriptive therapies is a bit like the old “tastes great-less filling” debate: It doesn’t really take us anywhere. Is cure more about empathy or cognitive restructuring? A caring relationship or skill acquisition? Active listening or exposure to feared stimuli? Answer: Yes!
I think what Dr Allen and I are both saying is that the field is moving in the direction of an old-yet-new psychological remedy that I propose we label POT/BEER: Plain Old Therapy, But Empirical Evidence Required!
What works, and why?
The human element that Dr. Allen so eloquently describes has brought comfort and healing to innumerable distressed souls through the years, not only by mental health professionals, but also by members of the clergy, school teachers, family members and other caring individuals who listen well and without judgment. This must continue to be appreciated and cultivated, even (and especially) as we introduce new, more prescriptive, interventions based on the latest research. At the same time, we must seek to better understand how, why and under what circumstances these “common factors” work.
This is not as obvious as it may sound. For example, when therapy relieves depression, patients and therapists alike may give an assortment of explanations: Because I felt accepted and understood. Because I helped her to better understand her past. Because of increased self-affirming thoughts. Etc. All of these processes may have, in fact, occurred, but what was the actual mechanism that lifted the depression?
This is something that we in the research arena seek to understand, because the short answer at this stage is we really aren’t sure. What’s more, we cannot assume that all common factors are helpful for all people.
For example, is empathy beneficial for all patients?
A lesson learned in therapy
This may seem like a silly question: Isn’t empathy good for whatever ails you? I will never forget the lesson I learned early in my career from a patient who consulted me for interpersonal problems that she was having, both at work and in her personal life. The reason was clear—she was a bully! Think Meryl Streep in The Devil Wears Prada: a self-made woman who worshipped her creator! She was always right and God help anyone who disagreed with her. Her controlling style made ordinary conversation difficult and therapy well nigh impossible.
Or so I thought, until it occurred to me that my usual efforts to communicate warmth, understanding and acceptance were going nowhere. To the contrary, this woman viewed such “softness” as a sign of weakness, to be disrespected or even exploited. When I adjusted my stance to one of greater distance and started communicating some actual disapproval, her behavior changed dramatically; she actually started listening a bit, and we were able to do some meaningful work.
We can speculate about why this proved helpful; but, the fact is, I was improvising—flying by the seat of my pants, because there was (and is) little in the research literature about matching my relationship style with a specific individual’s problems. As a clinician, I recognize this as part of the artistry that Dr. Allen describes. As a scientist, however, I find it less than satisfying. And as a teacher, I know that “improvise” is an instruction that sends therapist trainees into a state of panic. I hope it is not unrealistic to hope for greater precision in our interventions as our science advances.
As Dr. Allen notes, research into curative factors is in its infancy. We need to know what each individual needs and why he or she gets better. On the other hand, I suspect that how we help that individual get better will always share much in common with Plain Old Therapy. Indeed, it is safe to say that simple humanity will always be a key ingredient in the elixir of healing.