Critical Values Based Practice Network

C-VBP-N

Being Therapeutic

Written by Philip Houghton on . Posted in Clinical Psychology Bite-Size

Being Therapeutic

Issue 3 – June 2008 Author: Bob Diamond (robert.diamond@nottshc.nhs.uk)  

Key points

  • Therapy and therapeutic relationships are shown to be helpful for service users approximately 50-60% of the time, although some sources suggest the figure is lower.
  • Many studies over a number of years looking at outcome in therapy have shown there are few differences between particular therapeutic models.
  • Common factors in therapy such as, trust, warmth, understanding and acceptance may be the most effective factors in therapy.
 

Implications for practice

  • All staff members working in Mental Health Services have the potential to provide service users with effective therapeutic approaches.
  • Collaborative discussions involving respect, dignity, trust and acceptance are core to building therapeutic relationships.
  There are literally hundreds of specific models of therapy currently practised. Broadly speaking, therapy appears to be beneficial in 50-60 % of instances. The overwhelming evidence on outcomes in therapy suggests that the specific model of therapy used plays only a small part in influencing positive outcomes, at most explaining about 15% of the effect of therapy. A review of therapy research concluded that the effectiveness of therapies is not due to the many variables that apparently distinguish one particular approach from another, instead “it is principally found in the factors that all therapies share in common…the underlying premise of the comparative studies, that one (or more) therapy would prove superior to others received virtually no support” (p.xxii) 1.   Other than the specific model of therapy, the following factors appear to influence the outcome of therapy. 1) Extra-therapeutic factors account for 40%; these include the level of client interest in attending, client histories, clients’ social environments, whether or not support networks exist and “spontaneous improvement”. 2) Common factors in therapeutic relationships account for 30% in positive outcomes, these include, warmth, empathy and affirmation. Further, the therapeutic alliance has been described as developing shared tasks, goals and bonds; both the client and therapeutic worker must agree on the goals and processes of therapeutic work and such work requires interpersonal attachment where mutual trust, confidence and acceptance exists. 3) Hope and expectation in therapy appears to account for15% of positive outcomes.   Some sources are less convinced about the effectiveness of therapy 2. Evaluation of therapy is fraught with difficulties 3. What exactly is being reported is problematic. People may report appreciating the experience of psychotherapeutic approaches despite feeling much the same as they did at the outset. There are many problems with outcome research, including limitations in the range of people in studies, the lack of real control conditions and no longer-term follow-up in many instances. We also know that between 30-50% of people involved in outcome evaluations of therapy either refuse or drop out. As such it may be helpful to adopt a more modest position regarding the usefulness of specialist therapy. For instance some research suggests that Mental Health workers with less than extensive training in therapeutic models may be as effective in therapeutic relationships as extensively trained psychotherapists 4. Furthermore, NICE recognises, “Indeed, the importance of organising care, so as to support and encourage a good therapeutic relationship, is at times more important than the specific treatments offered ” (p.9 NICE Depression Guideline). It may be that the common factors in therapeutic relationships are central, including building up trusting respectful relationships based on collaborative negotiation and agreement over what is trying to be achieved.   It has been proposed 5 that the therapeutic alliance is about: helping clients to do the things they want in life, by giving information, advice and help to enable clients to make informed choices and providing support to enable clients to make their own decisions. This essentially involves affording clients power and control, ultimately aimed at enabling people to gain control over their problems and lives.   To be human is to strive to make sense of our lives. We search for confirmation of our experiences, a validation of our senses. Distress arises the more our experiences are invalidated. We are more likely to be invalidated the more detached, isolated and alienated we are from others and society. Well-being is associated with a sense of belonging, making sense of our lives and if possible regaining some influence or control.   Therapeutic relationships appear to be about: comforting, clarifying and enabling 6.Therapeutic relationships will always be individual and personal but it appears the following three elements are essential: developing trust and respect, providing an opportunity to make sense of experiences and if possible gaining some influence over personal circumstances and providing practical help to access personal, material, home and family life and social resources as described by Hagan and Smail (1997) 7.  

REFERENCES

  1. Hubble, M. A., Duncan, B. L., & Miller, S. D. (2005).The Heart & Soul of Change: What works in therapy Washington  American Psychological Association.
  1. Epstein, W. M. (2006). Psychotherapy as Religion: The Civil Divine in America. Reno: University of Nevada Press. 
  1. Moloney, P. (2006). The trouble with psychotherapy. Clinical Psychology Forum, 162, 29-33. 
  1. Berman, J.S. & Norton, N.C. (1985) Does professional training make a therapist more effective? Psychological Bulletin 98, 401-407.
  1. Perkins, R. & Repper, J. (2001). Working alongside people with long term mental health problems Cheltenham: Nelson-thornes
  1. Smail, D. (2001).The nature of unhappiness. London: Robinson
  2. Hagan, T. & Smail, D. (1997) Power-mapping – I. Background and basic methodology. Journal of Community and Applied Social Psychology, 7, 257-267.
Key Text: Roth, A. & Fonagy, P. (2006). What works for whom?: A critical review of psychotherapy research. New York:   Guildford press

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