In thinking about how to best address these issues I first thought about trying to delve more into the research, but as the author of the New York Times article noted, the research is complicated and at times even confusing and contradictory. Instead, I decided to focus on questions that I have asked myself as a practicing clinician of approximately 40 years, that focus on the issue of therapeutic effectiveness and why people choose to stay in or leave therapy.
- Why do some people who appear to really need therapy (or more therapy) choose to stop therapy even though they still appear to be struggling with significant problems and/or experiencing significant distress?
- Why do some people who I firmly believe do not seem to be changing, do not seem to be deriving any real benefit from our sessions, want to continue therapy?
- Are there things that I could have done differently (an alternative treatment approach, the use of other interventions) that would have helped people who I firmly believe have not derived any benefit from therapy (note: some of these people have told me therapy has not been helpful or clearly implied that)?
In addressing these questions a few caveats are necessary. First, these questions are narrow, and address therapy’s helpfulness (or lack of benefits) for those who choose to seek and start treatment. While the question of why people clearly struggling with mental health concerns (and who poses the resources to seek professional help) chose not to do so, is beyond the scope of this blog. Second, in this blog we are only referring to adults who seek services. Children and often teens are often brought to therapy by parents which raises other issues and complexities to be discussed at a later point. Third, the “answers” offered below are not really answers to these questions but thoughts and reflections on the complex issues involved in trying to ascertain if therapy is helpful, and if so, why and for whom. Fourth, I use case discussions (where identifying information is excluded and the pronouns “they” and “their” are employed to further obscure clients’ identities) to help elucidate these issues.
Starting with the last question, I remember one client who clearly told me that therapy was not helping. This individual requested a change of therapists and told me that I was not viewing their problems and struggles appropriately, i.e., that their problems were extensive and profound. This same client noted that they had “been too much” for their last therapist, whom they also fired. This previous therapist utilized a Cognitive Behavioral approach in their work, and was a respected practitioner in the community. I referred this client to another therapist. The third therapist subsequently shared with me, after the client ended treatment due to a job/insurance change, that they were very worried about this person’s decisions and believed the client made no progress. In reflecting on this case I have struggled with the idea that this was a person whose self definition, identity, was based on seeing themselves as struggling with complex issues, and what they were seeking was someone to validate and reflect this back to them. I often hesitate when I think about this explanation as it sounds like I am blaming the client for their not changing (something I believe is inappropriate for therapists to do), but I am at a loss when thinking about other explanations. There are some instances where people choose to stop or not even really engage in therapy when they understand fully what making changes means. Years ago I briefly worked with a severely anxious individual, whose behavior was extremely restricted by their fears. When I suggested ways to work to lessen their anxiety and expand their repertoire of behaviors, the person responded, “what, push myself out of my comfort zone,” and when I acknowledged that this was what I meant, treatment was over. This individual appeared to find their anxiety, which severely constricted their life (they did not drive, would not go or do many things without someone with them) something that they would rather live with than face the challenges of confronting and working to lessen their anxiety through a Cognitive Behavioral Therapy combined with exposure therapy (widely used and supported approaches for treating anxiety). These clients left me struggling with many questions including whether a more person centered approach, one in which I focused on empathizing with their feelings and validating their perceptions may have been more helpful, or whether such an approach would have only had a palliative effect and left problems unchanged, but the client feeling more supported.
The second question reflects a scenario that is likely all too familiar to many clinicians, particularly those working in private practice settings, in which our income/livelihood is dependent on a full caseload: why do some people continue therapy even when they clearly acknowledge they are not improving? This question is one I feel more confident in answering. People want to be understood and listened to. A former colleague of mine used to say, when reflecting on therapy, “all we do is keep people company.” Several of my former professors (all academic researchers) made a similar point, only in more acerbic ways, one referring to therapy derisively, as the “second oldest profession” (the oldest being prostitution). Others referred to therapy as a “rent a friend” process. I prefer my answer: many people want to be listened to and empathized with. They may not even really want to make changes (or may feel change is impossible for them). I had one client who clearly stated they were too depressed to try to do anything to change, but wanted to continue therapy because they felt the therapist understood their plight. This case left me struggling whether accepting their request was condoning their staying depressed or was offering the only type of care that they could accept at the time.
Finally, why do some people stop therapy prematurely (prematurely being defined by the therapist)? I am not referring to instances in which clinicians believe that more and deeper change is needed as these may be situations where a different therapist subscribing to a different model of treatment might not agree. Rather, I am referring to individuals who often quite explicitly will state that they are still struggling with a problem and then stop therapy. In many ways this is a daunting question. Particularly when I believe (though clearly I could be mistaken) that I have a good working relationship with the client. Of my 3 questions, this one puzzles me the most.
In thinking about these issues it is important to acknowledge that it is likely that there have been times when my approach, interventions I tried or suggested, and how I responded to the client, were probably not experienced by a given client as helpful. I remember one situation in which I clearly prematurely pushed parents to consider an approach to solving a problem that they were not ready to hear. Specifically, their child was a finicky eater, but in good health. They were not willing to consider the idea of accepting this problem as developmental and letting their otherwise healthy child outgrow this problem. While I believe my recommendation was correct, my timing in making this recommendation was likely the issue. Clearly, there are times when therapists recommendations, and approach to therapy are not a good fit for a client. Most likely the best solution to this dilemma is for therapists to explain to their clients that what they recommend may not fit for the client, that the client needs to let the therapist know this and that the therapist be clear that they will then work with the client to explore other options/solutions/approaches (or a different clinician) that would likely be a better fit for the client. However, this warning is not always sufficient or not remembered by some clients, and likely needs to be reiterated during treatment.
There is one research finding that I find most convincing, which is the benefit of feedback-informed therapy There is extensive research suggesting that when therapists obtain regular systematic feedback about how therapy is progressing that they achieve better outcomes. Scott Miller and his colleagues (1) along with a number of other researchers including Michael Lambert, PhD (2) and others (3) have repeatedly provided evidence to support this finding. Unfortunately, the challenges of the pandemic and remote work have derailed and complicated the use of this approach. As a practice we have suspended our use of feedback informed therapy because it was too cumbersome to do on-line.
In conclusion, I have no substantive conclusion on what makes therapy work for whom. I find myself worrying that the “YAVIS” syndrome may be one explanation for why some people benefit from therapy. The YAVIS syndrome is a term that was bantered about when I was in graduate school. According to this principle, clients who are young, attractive, verbal, intelligent and successful, are likely to derive more benefit from therapy. In thinking about parallels to this thought I am struck by the idea that many physicians would likely admit that it is far easier to treat milder than severe problems. A second plausible explanation is that clients who seek help for problems sooner, rather than later, are also likely to be easier to help. Third, there is evidence supporting the notion that some therapists (4) and some procedures or approaches that may be more effective, for specific problems. For example proponents of Cognitive Behavioral Therapy have argued that this approach is the most effective therapy for treating anxiety disorder (5). Fourth, feedback informed therapy also appears to contribute to improved outcomes as well (1,2,3 ). Finally, it appears well established that many people benefit from therapy. However, who they are, what the therapy or therapies are that help them, why they benefit, and what are the key ingredients or elements of therapy which provide the most benefit, is still often shrouded in mystery.
- Scott Miller and his colleagues have written and spoken extensively on this issue. A few examples of this research are:
- Miller, Scott (2013). “The outcome of psychotherapy: Yesterday, Today, and Tomorrow”. Psychotherapy. 50 (1): 88–97. doi:10.1037/a0031097. PMID 23505984.
- Miller, S.D., Duncan, B.L., Brown, G.S., Sorrell, R., & Chalk, M.B. (2006). “Using formal client feedback to improve retention and outcome: Making ongoing, real-time assessment feasible”. Journal of Brief Therapy. 5 (1): 5–22.
- Multiple links to articles, blogs and podcasts on this topic are at the website: https://www.scottdmiller.com/.
- Feedback-Informed Treatment in Clinical Practice: Reaching for Excellence 1st Edition by David S. Prescott (Editor), Cynthia L. Maeschalck (Editor), Dr. Scott D. Miller PhD (Editor).
2. See the work of Michael Lambert, PhD, who has written and researched feedback informed therapy extensively.
3. See the work of Jeb Brown, PhD and his colleagues on their website, for Acorn, who have worked extensively on this issue: https://acorncollaboration.org/articles
4. There is much research on this controversial issue. Scott Miller PhD and his colleagues argue that there is clear evidence to support this and there is research based evidence that concurs with this conclusion.
a. See Miller’s article on “Supershrinks” at: https://www.psychotherapynetworker.org/article/supershrink
b. For a series of articles on this issue
5. See this NIMH article summarizing the research on Cognitive Behavioral Therapy and anxiety. However, it should be noted that proponents of other treatment models as well as those that argue for a common factors model (in which the key components of treatment efficacy are not model dependent) would disagree.