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The Therapy that Works...

Why do some clients have a faster turnaround than others? Why do some clients not see change at all? Or flat-line in their progress? Is there a therapeutic modality or specific therapist that works better than others? Here are some things to consider when thinking about what will or will not work for you as a client.

Psychologists now understand that the creation of an expectation to benefit from therapy is one of the common factors associated with a positive therapeutic outcome.

The therapy that works... is the one you believe in.

I'm not interested in all therapeutic modalities, even the most popular ones. There are some that I don't think I could take seriously and benefit from. Or there may be pieces of a larger modality that I don't believe in and would probably not benefit from just for that reason. It would make sense for me to seek out modalities that I expect some benefit from. The fact that I am not interested and don't believe is a block to its potential success on me.

This has nothing to do with the evidence of whether a modality is most likely to work or not. It's more about the client's belief in the modality or for it working on them in particular. A belief in it and an interest in being a part of it. Even if a modality has solid evidence backing it up, that doesn't necessarily equal belief or taking it seriously by a potential client.

Belief in the modality is important. In fact, belief in the potential of therapy in and of itself is important and "...may be even more vital to the psychotherapy process than is often acknowledged" (Greenberg 2006). Not everyone buys into therapy as a legitimate field.

I used to hypnotize my friends when I was in high school. It didn't work on everyone, only those who believed they could be hypnotized or that hypnosis was even a thing at all. Belief was essential to the process of being hypnotized. Same for therapy. You have to buy into it. You have to have some level of belief and positive expectation. At least a little to show up and start the process.

Clients may do some research and find a modality that they determine will be the most beneficial. But when it comes down to it, the therapist themselves are probably more indicative of success than the specific modality.

Do you believe in the person providing the service?

Besides the belief in the modality, the client has to have some belief in the provider as well. And I think this is more important than the modality - "...the quality of the alliance [is] more predictive of positive outcome than the type of intervention... " (NCBI). If you think the provider is a [fill in the blank], then no mater what they do, it probably won't go very far. The therapeutic alliance is the most important part of change in therapy (factors outside of therapy play a much bigger role though).

So the client needs to have some belief in their ability to help in general, but also in their specific abilities. Things like:

  • listening

  • validating

  • understanding

  • holding the client in positive regard

  • knowledge base

  • ability to adapt to the needs of the client

If the client does not believe in the therapist, the possibility of therapy being as effective as it could be is probably reduced.

This lack of belief in the therapist could be due to:

  • the therapist's actual shortcomings in their role as a therapist

  • the client's capacity to trust and be vulnerable

  • ruptures in the therapeutic alliance

I expect that my clients are going to have some difficulties with trust and vulnerability. That's probably going to be something that we work on. It's pretty normal for therapy.

It's up to me to make sure I am doing as good as a I possibly can when it comes to basic therapeutic skills. I need to be in my most safe and social state, as much as possible, when I am providing therapy. From there, I can use those fundamental skills with more efficacy. If I lose access to my state of ventral vagal safety, then I also lose access to necessary pieces of co-regulation.

It's also up to me to notice and repair ruptures. An easy way of doing this is by simply asking the client for feedback at the end of a session. "Was this session helpful for you?" "Is there anything I did today that you hated or would like to see different?" But I also regularly provide opportunities for feedback during a session - "I want to make sure I'm doing a good job listening to you" and then opening a question or discussion.

I listen to those ruptures within my nervous system; the flight/fight, shutdown or freeze energies that may pop up. I discern if these are empathetic feelings, my own feelings or indications of a rupture, then open the dialogue with my clients.

The point is the belief in the therapist is essential. And there is a lot the therapist can do to build and support that belief. The belief in the specific therapist comes from the rapport with the therapist. And a stronger rapport leads to a higher chance of a positive outcome.

Is it the right time?

Another thing to consider in what "works" or not is the timing of it. Although I am not interested in Therapy X currently, it might be of interest to me later. So my lack of personal belief in it is a hindrance to success right now, but maybe not in the future. I may be looking for something with a more novel feature. Or maybe there's a therapist influencer out there that peaks my interest who uses Therapy X. At that point, I may become more interested.

If we look at the five stages of change model, a client in the precontemplation stage of change is probably not going to respond well to interventions that are more for the action stage. The intervention is too early, they aren't quite there yet. The client that arrives to the therapy office due to a court mandate to address their addiction is potentially in the precontemplation stage. They aren't seeing their addiction as a problem. Working on how to stop their addiction doesn't match their stage of change.

It may not be the right time for a specific modality or a specific technique. The client might not be ready to talk about the trauma narrative. So meeting with a therapist that uses a modality focusing on the narrative might not be the best idea. We can help the client to prepare or become more interested in a technique. Simply explaining it to them, the reasoning of it, what to expect and how we apply it can help.

But for the client that doesn't want to go into their trauma narrative, they might want someone that focuses more on somatic stuff. Or maybe focus their time on psychoeducation around trauma and the body. As they learn more, they may become ready to go into their feelings or even into the story. (BTW I talk about whether or not I think telling the trauma story is necessary in the first Therapeer Content Event.)

Attempting a modality before they are ready probably reduces the chances of success. When I work with my clients, I have to be assessing and collaborating with them about their readiness to make change and be a part of techniques that I may use. Discussing the plan with them and making an agreement on these things is a good way to build their belief in both the process and the provider. If they believe in the process and believe in the provider, their willingness to try something different might increase. Or to be more open to thinking differently about their presenting problems. Opportunities and readiness for change opens up once the other pieces are more solidified.

We put a lot of emphasis on the techniques and modalities, but these things are not necessarily going to be the biggest predictors of change for clients. The therapy that works is the one that the client expects to work. With the clinician they expect to be helpful. At the stage they are ready for change in.

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