What actually makes therapy work?:
Updated: Jul 6
So you wanna be a better counselor? Pt. 8
A few weeks back I hosted a guest post from Barry McInnes entitled "Are You Any Good…as a Therapist?" He's one of the few other therapist bloggers in the outcomes/deliberate practice space and I'd been a follower of his work for a while.
I was stoked to have him on.
I was even more stoked when he asked that I return the favor.
So I decided to write this post on the single most important factor in therapy. I hope you enjoy it!
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I always wanted to be a master therapist. I think that’s why when I learned about all the problems in the field, I was stunned.
I mean we have 40 years of stagnation in outcomes, massive problems with gurus, and certifications that over promise and under deliver. Yet, the research is pretty clear- out of 100 clients, 30 of them will have some change and about 20 will “recover”1. That’s the same level of effectiveness as the flu vaccine!
Despite our lack of improvement, therapy is effective. How? What makes therapy effective?
What makes effective counseling? The Therapeutic Alliance.
When researchers study the process of therapy, they find a few key variables contribute the most to change. Consistently, it seems that the most important thing therapists offer clients is (drum roll please) the Therapeutic Alliance.
This is usually where all my snuggly therapist friends start holding hands and singing kumbaya. “We knew it!” They giggle, “People just need to be loved. And if we love them enough they will change! Let’s all go out for ice-cream afterwards! Slumber partyyyy!”
Before you and your bffs gorge yourself on ice cream in celebration of the rainbow magic of healing relationships, let’s just stop for a minute.
The Therapeutic Alliance (TA) is much bigger than merely how much you and your clients like each other. Let me say this again. The Therapeutic Alliance is MORE than just the client-therapist bond. That’s just one of the three major components.
The other two parts of the Therapeutic Alliance are:
client-therapist agreement on goals, and
client-therapist agreement on steps to reaching those goals.
These three parts, the bond, goals, and steps, are the three parts of the alliance. Miss even one and you have an Alliance Rupture. And ruptures will kill your therapeutic work.
A few years back I had a phenomenal first session. Like I really rocked it2.
I was working with this older guy who, through a series of traumatic events, ended up his nephew’s guardian. Despite this client’s best intentions, he was really struggling to parent his nephew.
Something about his story kept bothering me. Finally I stopped the session to ask, “hey, does any of this have to do with your brother?”
My client froze, then started bawling. “How did you know? How did you know? How did you know?” he said again and again.
I was quite pleased with myself.
You can imagine how surprised I was when 3 sessions later he dropped out of therapy. Confused, I called him up and asked why he dropped out.
“Well,” he said, “to be honest you kept asking me questions about my brother and my past, and I just wanted to focus on the present with my nephew.”
“Well, I’m sorry,” I said. “I wish I would have been more supportive so that would have been easier.”
“Oh no. You’re definitely in the right profession,” he said with a rare air of certainty. “You’re really empathic. It just wasn’t where I wanted to go.”
Even with a strong therapeutic bond we had an Alliance Rupture and it killed our work. He had different ideas about the steps required to meet those goals, so he dropped out.
1 Way to Avoid Alliance Ruptures
So how do we avoid Alliance Ruptures? There are many different ways. I'll tell you what I do.
One thing I’ve started doing is a Goal Sheet. At the beginning of our 3rd session I say to my clients, “Today we’re making a goal sheet. This is going to help us establish a goal for therapy and clear steps to meet that goal. So tell me, what is your biggest goal for therapy?”
While this looks like a watered down treatment plan, it’s not. It’s really an assessment. By working this way I’m assessing what the client thinks are the goals and steps of therapy. Clients generally fall into three types, Concretes, Comfortites and Confused.
Concretes generally respond to the goal question with something like, “Well, I know I need to work out. So to get over my anxiety I need to start working out again.” These people believe that they will change if they can learn the right coping skills. Knowing this, I know if I want avoid Alliance Ruptures, I’ll have to give them something concrete to do. However, instead of me trying to puzzle out which coping skill is right for them, I just feed their own solutions back to them. I’ll say, “Okay, so you’ve got a plan. You need to work out. I’ll check back in with you about this next week.” The point is not that this coping skill fixes their problem. Sometimes it does, sometimes it doesn’t. The point is, we no longer have a rupture. They no longer walk away saying, “my therapist never gave me practical steps for resolving my problem.”
Comfortites will say something like, “I just need to process through my feelings.” They are coming to therapy to have someone validate their experience, and as long as this happens we’ve got a strong alliance. I think these tend to be therapists' “favorite” clients because they believe in the same goals and steps as many therapists: that talking about your feelings with a caring other will help you.
The third type of client type, the Confused, will say something like, “I really have no idea. The whole thing is confusing. I don’t know how to answer your question.” To which I say, “Perfect, that means our main goal is just getting clear!” The goal then becomes helping them get clarity so they can naturally shift into either a Concrete or a Comfortite.
It sounds simple, but it’s not. It almost always takes me a full 50 minute session to go through the full process and there’s a lot of nuance that goes into it all. The most important thing is that working this way gives me a way to assess what the client expects, and use those expectations to avoid Alliance Ruptures. I’ve seen it do wonders for my work. I know this because I track my data. About two years ago my average client came for 5 sessions. Now my average client comes for about 20 sessions.
Let's be clear. This way of working is not "magic". It's just my systematic attempt to privilege all parts of the Therapeutic Alliance early in therapy. My hope is that you too will think very deeply about how you can privilege all three parts of the Therapeutic Alliance from the very start.
Help, my therapist doesn't get me!
Many therapists have a hard time really feeling the weight of Alliance Ruptures because their own ideas of change, their own ideas about what the goals and steps of therapy ought to be, get in the way. They believe that clients have to talk about their past, deal with underlying trauma, or do some other type of intervention to make progress.
My point is not that your interventions are wrong. My point is there is a subtle and insidious invalidation that happens when we ignore the goals and tasks of the client. My point is your clients think you don't get them.
The weight of this sort of invalidation became very evident to me a few months ago when I was talking with a female colleague. Somehow or another ended up talking about her cycle. She’d been having issues, had seen multiple doctors, and was growing more and more frustrated with the process.
“It’s actually really common,” she said, exasperated. “All the women in my friend group have some sort of problem with their cycle, and we’ve all had the experience of going to the doctor and just being dismissed.”
“Like they tell you it’s not a problem?”
“Sometimes. It’s more like how they treat it. They say something like ‘yeah, that’s normal. Anything else you want to talk about?’ So it’s normal. What are we going to do about it?”
“It’s like they aren’t taking your distress seriously.”
P.S. If you liked this article I suggest you check out Barry's McInnes' article on the therapeutic alliance. It’s super easy to read, but also super academic. A great mix! I’ve also got another article on the therapeutic alliance you can read here (released 7/11).
1. These are, of course, general benchmarks and the numbers vary. I’d advise you to track your own numbers at your agency and get local benchmarks. My sources for this is a personal conversations with Scott Miller, as well as Neil Jacobson’s classic article “The Overselling of Psychotherapy.” Email me for a copy of the article.
2. All stories about clients are mixes of various clients with identifying details changed. No identifying client information is revealed in these stories.