Currently, about one-third of all adults in the U.S. are receiving some form of psychotherapy. While the idea of talking to a therapist is still taboo for some, more people are seeking therapy than ever before in history. This is a positive trend partly born out of an effort to destigmatize conversations about mental health, and the advice to “just go to therapy” now seems to be a standard reaction to anyone experiencing a mental health concern. However, in a Wired article, Eleanor Cummings writes that “anyone who’s actually tried it can tell you, therapy often sucks.” In fact, she notes that only 50-75% of people derive some benefit from therapy, 5% report worsening of their condition, and the rest report neither benefit nor harm. Clearly, there’s more to the story than “just going.”
As with nutritionists and personal trainers, therapist skill exists on a spectrum. But surprisingly, a therapist’s level of professional experience does not appear to correlate with therapy outcomes. So what else might explain why therapy works for some and not for others? Apart from finding the appropriate treatment method, research analyses by the American Psychological Association (APA) indicate that the most critical variable is the relationship between the patient and therapist. But how does one find a good fit and build a strong patient-therapist relationship?
Key elements of the patient-therapist relationship
In 2019, the APA’s Task Force on Evidence-Based Relationships and Responsiveness conducted 16 meta-analyses on the most recent literature on relationship factors in therapy. The Task Force investigated evidence on the importance of several elements of the therapy relationship in improving patient outcomes, and based on their findings, they then categorized these elements into three groups: “demonstrably effective,” “probably effective,” and “promising but insufficient research.” Those which they deemed demonstrably effective included:
1. Therapeutic alliance
Therapeutic alliance is a term which is often broadly applied to the je ne sais quoi qualities defining the bond between a therapist and patient, but to put it somewhat more concretely, alliance is conceptualized as the mutual level of engagement in the therapy on the part of both patient and practitioner, a factor which appears to be critical to treatment success across virtually all psychotherapeutic contexts. Both the therapist and the client should be active and equal participants in the therapy process, working together to build an effective partnership. A related factor – which the Task Force termed “cohesion” – similarly applies to group therapy, as extension of the partnership bond across all members of a psychotherapy group is likewise correlated with better patient outcomes. While cohesion and alliance may be difficult to judge prior to starting treatment, understanding the importance of this bond is important for entering therapy with a positive, open attitude, as well as for evaluating the progress and potential of ongoing treatment.
2. Goal consensus
It’s simple: your therapist is more likely to help you reach your treatment goals if you can both first agree on what those goals ought to be. Look for someone who encourages this mutual agreement and clarity on goals and helps to set realistic expectations. And this consensus is not limited to the start of treatment – an effective therapist is likely to solicit your thoughts on how treatment is progressing in order to ensure you both remain on the same page or are able to modulate treatment as needed.
Empathy, by definition, is the ability to understand another’s emotions, thoughts, and difficulties from their point of view – an essential step in understanding a psychotherapy patient’s concerns and identifying potential solutions. Without this, I don’t see how the other elements on this list could even be possible. Is anyone really surprised that the Task Force meta-analyses showed that empathic therapists consistently achieve better patient outcomes, regardless of the form of therapy?
A related concept is the element which the Task Force termed “positive regard and affirmation,” defined as the sense of acceptance, caring, and support a therapist demonstrates toward patients, regardless of their emotions or behavior. To be genuine, this reaction stems from a sense of true concern and empathy, which some therapists demonstrate by sharing their own related experiences and feelings. Insufficient level of positive regard – such as through emotionless or disinterested reactions on the part of the practitioner – is associated with treatment failure.
The Task Force concluded that these and other relationship factors are as important as the appropriate treatment method when it comes to achieving a positive outcome in therapy. So, if therapy fails, a poor psychotherapy relationship may be a likely culprit, but how does one find the right fit?
Finding the Right Fit
In an article published by the University of Vermont Larner College of Medicine, Dr. Tom Delaney, an associate professor at the school, echoes the APA’s stance that a good fit between therapists and patients is crucial to successful treatment. Delaney suggests that treating the first conversation with your therapist like a job interview is a good way to gauge compatibility right off the bat. Inquire as to the therapist’s success rate with clients like you and whether or not they are open to trying different approaches to treatment. This could be a means of gauging how collaborative and receptive to feedback a practitioner might be. Delaney adds that patients should not feel intimidated by a therapist’s training, credentials, or status as a health professional and should exercise their right to ask questions – a key step in building an equal partnership between therapist and patient.
That said, getting a sense of fit may be difficult before engaging in therapy. Delaney emphasizes the importance of frequent reflection on whether or not you feel valued and heard by your therapist, as well as whether you feel you’re making headway. If you’re not sensing a potential for progress with your current therapist, try raising the issue during a session, and if the situation doesn’t improve, it may be time to switch. (And that’s okay.)
Finding a good therapist may look similar to searching for a nutritionist or a personal trainer. Some are a good fit, and some are not. Some will help you, while others won’t. To engage with therapy, stick with it, and reap its benefits, it’s important to develop a strong rapport with your therapist. The qualities of alliance, goal consensus, and empathy are critical to that process and ought to be valued more highly in seeking an effective practitioner than years of experience or the rank of their training program. And if a connection simply isn’t there, it’s ok to switch providers, just as long as we’re being honest with ourselves in our reasoning – not liking what a therapist has to say should not be confused with a poor fit. Reflection, reevaluation, and honest conversations with providers help in assessing the potential for progress in a given patient-therapist pairing. Remember that therapy, as Cummings points out, is an art form often based on the strength of your interpersonal connection with a therapist, on which the success of therapy largely depends.