Why Does Psychotherapy Work? Look to the Intuitive Mind for Answers

 

Jerome Frank's 1961 book Persuasion and Healing popularized the idea of "common factors" that explain the benefits of psychotherapy, building on ideas that were first articulated by Saul Rosenzweig in 1936 and again by Sol Garfield in 1957. Frank's book emphasized the importance of (a) the therapeutic relationship, (b) the therapist's ability to explain the client's problems, (c) the client's expectation of change, and (d) the use of healing rituals. Later theorists emphasized other factors like feedback and empathy that are sub-components of the therapeutic relationship, and that can be clearly differentiated from specific behavior-change techniques like cognitive restructuring or behavioral reinforcement. Additional aspects of therapy that are sometimes identified as common factors include the opportunity to confront difficult past experiences, the opportunity for a "corrective emotional experience" with the therapist, and the chance to develop a sense of mastery over things that felt overwhelming in the past. Michael Lambert identified the client's own efforts for change as the most important common factor (in his model accounting for 40% of a good outcome), followed by the therapeutic relationship (30%), the client's expectation of change (15%), and finally specific techniques (15%: in other words, everything that the therapist actually does and says!). In the 1980s and 1990s, the study of common factors intersected with an eclectic psychotherapy movement -- for instance, Grencavage and Norcross's (1990) list included (a) client characteristics, (b) therapist qualities, (c) change processes [what Lambert would call specific techniques], (d) treatment structure, and (e) the therapeutic relationship. A 2014 article by Bruce Wampold and colleagues estimated that 30% of outcomes depends on aspects of the therapeutic relationship, 12% on having a consensus about goals, 5% on therapist characteristics like age or gender, and less than 1% on specific techniques. And a 2003 cluster analysis by Tracey et al. started from an extensive list but boiled the common factors down to just three: (a) the therapeutic bond, (b) information learned in psychotherapy, and (c) roles or structures that govern the therapeutic interaction. That's not too different from Frank's list in 1961. 

These common factors work mainly by way of the Intuitive mind. For example, the patient-therapist relationship (often called the "therapeutic alliance") has elements of empathic listening, a sense of connection, the therapist caring about the client (what Carl Rogers called "unconditional positive regard"), the therapist being genuine with the client, and the therapist maintaining positive feelings even when challenging or confronting the client. All of these come down to the fact that most clients like their therapists, respect them, and feel cared for by them. And liking other people is a deeply intuitive process. We tend to like people who are similar to us in some important ways, although this is most true when there is also a sense that the other person has a commitment to us. We like people more when we feel that they also like us. And we like people who are attractive in some way -- whether that's physically, in terms of social status, based on their knowledge, or in other respects. The therapist's ability to provide an explanation for our problems might also contribute to us liking them more, because a sense of shared reality is another determinant of how much we like someone. Good therapists know how to capitalize on these basic social psychology principles to develop a strong alliance. For instance, it has been said that a good therapist is someone who finds a way to like most people, in order to capitalize on the reciprocal-liking phenomenon. Therapists also deliberately mirror their clients' ways of speaking, tone of voice, or movement patterns to create connection through similarity; the pattern-matching triggers a reaction in mirror neurons in the client's brain to create a sort of resonance between two people. Eye contact is another good way to create connection -- when learning to be a therapist, I had to practice it in school. Many of these are basic persuasion strategies that are also used by peddlers, preachers, politicians, and others whose livelihood depends on their influence over others.

The second and third common factors in Frank's analysis have to do with expectancies and beliefs. If the therapist is persuasive in offering a credible explanation for the client's difficulties, the client is more likely to be helped. And if the client believes that change is possible (a belief that may be helped along by the therapist providing plausible explanations), then improvement is also more likely. Together, explanation and expectancy are probably the key elements of medicine's placebo effect. They could also collectively be described as "hope." Therapists use various strategies to cultivate this common factor. For instance, we see other people's information as more credible when we perceive the source as being an expert -- a good reason for therapists to display their diplomas and certifications on their walls, and to call themselves "doctor." We also are more likely to believe people when they seem to be trustworthy. People can increase their trustworthiness by saying things with confidence, by revealing the sources of their information, and by saying things that are internally consistent with one another. Paradoxically, one of the most effective ways to build trustworthiness is actually to admit to having been wrong about something: It conveys that you are more interested in the truth than in defending your own previous position, and helps your audience to believe that you got to your current positions honestly. Even though information seems like it should be a Narrative-mind influence on behavior, the Intuitive-level influence of therapists' explanations can be independent of whether their theories about the client's problems are actually correct! Overconfidence and self-importance are professional hazards for therapists. And unfortunately, therapists' confidence in their own explanations can sometimes be a source of conflict, especially if a therapist's strongly expressed view of the client's problem conflicts with a family member's or spouse's. 

The final group of common factors falls under the heading of ritual, and is perhaps the most deeply unconscious of the three. The term "ritual" means any repeated pattern of behavior that holds personal or cultural meaning, and rituals are a universal aspect of human experience. Some common ritual elements of therapy are (a) the location where the patient comes for treatment, (b) the start of the session including any review of homework or check-in process, (c) whether the therapist takes notes or recordings, (d) the process for keeping time and ending the session, and (e) the payment of the therapist's fee. Frank talked about the importance of the actual building in which a psychotherapeutic interaction occurs, noting that a large and modern structure or an ivy-covered college building can increase the efficacy of treatment by stirring up the client's positive associations with such places. Frank's tongue-in-cheek label for this phenomenon was the "edifice complex." Other aspects of therapy may also have a ritual significance: Freudian therapists, for example, sometimes have a Victorian "fainting couch" in their office as a callback to the original free-association methods of psychoanalysis where the patient was lying down. The HIPAA law affords special protection to psychotherapy notes, which have a sort of sacred status and are seen as being even more sensitive information than other mental health treatment records. And there is a large psychotherapeutic literature about fees: How they are negotiated, how therapists address missed payments, when and how the client pays, and other aspects of the financial relationship. Rituals help to set times and places apart from everyday life, to create a "holding space" in which previously unwanted or unacknowledged aspects of one's experience can be more freely discussed. And performing a ritual can have physiological calming effects that are stronger than those produced when someone just tries to relax. The psychotherapy literature recognizes that repetition of a ritual can have therapeutic benefits in and of itself, separate from any actual content that may be discussed within the ritualized boundaries of the psychotherapy session.

Common factors such as the therapeutic relationship, the stimulation of understanding and hope, and the rituals of psychotherapy seem to go a long way toward explaining why talk therapy works, e.g. as seen in the repeated finding that very different types of therapy have similar benefits for a wide range of clients and problem types. The client's Intuitive-level responses are key to all of these mechanisms of change. For example, if the client is not convinced by the therapist's explanations or does not feel that the therapist cares about them, then the treatment probably will not work. However, therapists can and do deliberately cultivate these Intuitive-level sources of influence to improve their ability as helpers.