What makes a therapist effective? Is it our therapeutic approach or modality? Or is it the relationship we build with the client? Overall, evidence suggests that the abilities of individual therapists may be a more significant factor in determining outcome than therapeutic orientation. For counseling students and already-established practitioners who want to enhance their skills, Norton has released a good starter book.
As a Licensed Clinical Social Worker specializing in grief, loss, and trauma, I found Psychotherapy Essentials To Go helpful, with techniques that can be integrated into a wide range of approaches and modalities. The book, written by Molyn Leszcz, Clare Pain, and Jon Hunter, with Paula Ravitz and Robert Maunder as editors, focuses on theories, principles, and practices that can improve any therapist’s effectiveness.
One of the most important variables that affect therapy outcomes is the therapeutic alliance, the authors write. This alliance is demonstrated by support, concern, and even confrontation from the therapist to the client. The book discusses ways to use a therapist’s own reactions (counter-transference) as a tool and resource. To achieve a therapeutic alliance, the therapist must convey empathy, responsiveness, interest, genuineness, and be able to build rapport, the authors write. Other factors include developing a shared understanding of a client’s relational world and encouraging client feedback.
What stood out to me was the discussion of “achieving psychotherapy effectiveness following a sequence that is firmly rooted in an understanding of the power of relationship dynamics.”
The authors write about a so-called tear-and-repair process where the therapist can get “hooked” into the client’s maladaptive relational pattern. In order to “unhook” and bring awareness to the client, they write, the therapist must use mentalizing and metacommunication. Mentalizing is being able to think about your own thoughts and feelings, as well as what someone else is thinking and feeling. It is the ability to value the fact that others have different intentions, beliefs, and understandings. Metacommunication, meanwhile, is communicating about communicating, and is used to repair an alliance tension. It is taking responsibility for contributing to the tension, exploring the client’s experience, and collaboratively reflecting on the experience.
In order to understand the client’s relational world, the book emphasizes, we need to understand attachment theory. Attachment theory, as therapists know, is about relationships that shaped a person’s internal working model. It relates to the patterns of attachment to their caregivers (what the authors call the there-and-then), the client’s current relationships (there-and-now), and the therapeutic relationship (there-and-now). The book gives a nice refresher.
Another important factor in therapeutic effectiveness, the authors write, is learning about the client’s interpersonal pulls, and being able to identify inflexible, automatic maladaptive behaviors that reinforce long-held beliefs. To this end, the authors describe the interpersonal circumplex: a diagram that assists in understanding how one person’s behavior influences another’s response. Two axes define the circumplex: a vertical axis, with dominance or control at the top and submissiveness at the bottom, and a horizontal axis, with friendliness at one end and disengagement at the other. Placing a person near one of the poles of the axes implies that the person tends to convey clear or strong messages (of warmth, hostility, dominance, or submissiveness).
An effective therapist must also take into account a client’s history of trauma. They must be attuned to and recognize unresolved trauma, and know how to ask clients about that trauma. As the authors write, unresolved trauma is profoundly aversive — it can lead to depression, anxiety, and anger, and often impacts relationships.
The book discusses these and other important areas for therapists to be aware of, and includes a comprehensive quiz and lesson plans, with an answer key, to enhance learning. It also comes with a pocket-sized reminder card that gives a short synopsis of each key part of the text, as well as a DVD to help the reader practice live role-plays.
As the authors caution, the book does not give a complete recipe for therapy, but rather guidelines to enhance one’s skills. It is easy to read and easy to understand, and can help therapists — especially new therapists — brush up.
Psychotherapy Essentials To Go: Achieving Psychotherapy Effectiveness
Molyn Leszcz, Clare Pain, Jon Hunter, Robert Maunder and Paula Ravitz; edited by Robert Maunder and Paula Ravitz
W. W. Norton & Company, March 2015
Paperback, 208 pages