How does psychotherapy work? – laying the groundwork in 100 daily tweets!

Following on from Interview 2 with Tom Warnecke for Psychotherapy Excellence, as it was fresh on my mind, I have written a sequence of 100 bullet points on the question "How does psychotherapy work?" - follow me on Twitter (@INTEGRA_CPD) to catch the whole series, one every day ...

The bullet points are not yet answering the question, they are just laying the ground work, attempting to remove some of the confusion and dogmatism around the question, and opening out the complexity of what we might mean by "it works".

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Look out for my upcoming series of 100 daily tweets on this long-standing conundrum in psychotherapy: HOW DOES IT WORK?

• Whether & how therapy works seems to me to be surrounded by lots of categorical & absolutist opinions, traditional dogma & blinkered theory.
• Can we find an integrative perspective that can embrace psycho-education, coaching, counselling & psychotherapy as ALL working in some way?
• How can regular meetings of two people sitting in a room, apparently having a chat together, be expected to have deep & helpful effects?
• The various therapeutic traditions have tried to address that question with their particular ‘theory of therapeutic action’, in jargon terms.
• There are profound divergences & paradigm clashes between the traditions regarding that apparently innocuous question of therapeutic action.
• With the general public considering psychotherapy supposedly as ONE recognisable profession,how can there be such fundamental disagreements?
• How can the profession have so many versions of what makes therapy work? How can they all claim to be doing the same psychotherapeutic work?
• Apparently, ALL psychotherapy works – across ALL therapeutic approaches, this is the most robust finding of decades of outcome research
• Research has established over and over again the so-called 'Dodo-bird Verdict': "all are winners and all must have prizes" – all therapies WORK – somewhat!
• However, the research statement ‘it works’ is based on averages, without any idea ‘WHY it works’ in a particular therapeutic relationship.
• Therapy-as we know it-DOES work,but in haphazard, elusive and unpredictable ways, subject to the vagaries of the two subjectivities involved.
• It DOES work, but that ignores and denies a) how damaging it can be, b) and the huge differences in effectiveness - see: http://bit.ly/1kPMvuI
• The contested and heated debate about WHETHER therapy works or not occludes the more fundamental question: What do we MEAN by ‘it works’?
• An embracing, non-partisan view of how therapy works would need to recognise that different people find a multitude of things helpful.
• When people say ‘it works’ they mean they’re finding things helpful or therapeutic,without distinguishing levels of experience referred to.
• Usually they mean: “something has changed, and I feel better”, but that could result from a variety of profoundly different change processes
• One of the most quoted modern references for theories of therapeutic action: Boston Change Process Study Group http://www.changeprocess.org/
• What doesn’t become explicit usually is the idea that there are different KINDS of change/change processes at different depths of experience
• Wilber provides a good starting point by distinguishing change via ‘translation’ from change via ‘transformation’ – what does he mean by that?
• ‘Translation’ means ‘change WITHIN an established structure’, whereas ‘transformation’ means ‘change OF the established structure’.
• That’s a useful distinction, but I find more helpful the following three-way distinction: ‘translation’, ‘contradiction’, ‘transformation’.
• Over the longer term, as Wilber proposed, every development goes through phases of translation alternating with phases of transformation.
• Once a new structure has established itself, change proceeds via translation WITHIN that new structure; but eventually that reaches a limit.
• At its structural,developmental limit, change via translation STOPS working, and a deeper transformation of the underlying structure occurs.
• Tracking -as we do in therapy- our subjective, experiential reality, that breakdown of the existing structure involves an internal struggle.
• That struggle usually involves –before the emergence/creation of a new structure- the destruction of the old: what I call: ‘contradiction’.
• I call it ‘contradiction’ because on the level of psychological reality, the person finds themselves – or is consciously – opposing the old.
• For example: in order to escape a negative addictive pattern, the person would decide to contradict and counteract the addictive impulse.
• However, simply contradicting the old, established pattern, as necessary a stage as it is in the change process, often does not work & last.
• In order to find a sustainable new structure, beyond fighting & contradicting the old structure, a more fundamental transformation is needed
• That’s because the contradiction impulse is usually caught within the logic of the structure it is trying to escape,in a simplistic reversal
• As Einstein said: we cannot hope to solve problems with the same kind of consciousness that created them. Transformation is then needed.
• The question how therapy works has different answers in each of the 3 phases of the change process: translation,contradiction,transformation
• What ‘works’ in translation, stops ‘working’ in contradiction, & is opposite to what ‘works’ in transformation. Different principles apply.
• Same is true for transformation and translation: what ‘works’ in one is profoundly unhelpful, counterproductive or dangerous in the other.
• So unless we appreciate the complexity of these different kinds of change, ALL of which are valid and subjectively experienced as helpful…
• … we will not be able to formulate a comprehensive theory of therapeutic action that is capable of embracing the inherent paradoxes.
• These 3 different modes of change underlie the confusing complexity of why different things work at different times for different people.
• As a client,what I want my therapist to have is a comprehensive view that is not habitually biased towards one or the other of these 3 modes
• What we can’t expect as client/therapists is lasting structural change when we’re applying only principles of translation and contradiction.
• What we mustn’t demand as clients and mustn’t promise as therapists is the expected results of one mode by the principles of the other.
• The deeper the change that is longed for, the higher the stakes, the less predictable the outcome and the more dangerous the procedure.
• Psycho-education, coaching, counselling and psychotherapy all offer themselves to be helpful and they all ‘work’ to some extent some times.
• They all need to work WITH and WITHIN the client’s existing personality structure in order to (Rule No 1) ‘meet the client where they are’.
• But the various disciplines differ & struggle when what is needed is to CONTRADICT or TRANSFORM the client’s existing personality structure.
• more to follow ...

Some of your COMMENTS and my REPLIES:

• In response to: How can regular meetings of two people sitting in a room, apparently having a chat together, be expected to have deep & helpful effects? I suggest you look at "Essential Research Findings ... The Facts are Friendly" by Mick Cooper - or was that a rhetorical question?
  MS: It WAS a rhetorical question from the viewpoint of the public, as part of my series of tweets on how therapy works. Mick's research shows that therapy DOES work, confirming the famous Dodo-bird verdict, but does not answer the question HOW. There are MANY ideas of HOW therapy works, but clients rightly ask: how come these ideas are so varied and contradictory?