Ellen Driessen is a psychologist in the Netherlands who believes, to the contrary, that the field has not yet unlocked the full potential of talk therapy. Driessen’s Twitter bio describes her as a “passionate depression treatment researcher,” and she has devoted herself in recent years to finding ways to maximize therapy’s effectiveness. Her goal: to determine which kinds of therapies work best for which kinds of patients, in the hope that those targeted pairings will yield better results. In her own practice, when patients turn to her for guidance about what treatment to choose, she often feels frustrated by uncertainty. The finding that all types of therapy work equally well, Driessen believes, could be hiding the variation that exists from person to person. Given the state of research, it is impossible to know what to recommend for an individual patient. “I don’t know which of these treatments will work best for you,” she resorts to saying. “And that is something that I, as a clinician, find very unsatisfying.”
Most studies do not break down the results of various psychotherapies by type of patient — by gender, for example, or comorbidities, or age of onset of illness. The trials are too small to generate statistically meaningful results for those categories. Driessen and colleagues are undertaking the ambitious task of going back to the researchers on at least 100 trials to procure identifying details about patients, so that their samples will be large enough to allow them to determine whether certain kinds of people are more likely to respond to one kind of therapy or another. The project will most likely be underway for a decade before they can tease out matches between practice and patient.
Another growing school of research, meanwhile, hopes to move practitioners away from adhering strictly to one school or another, by identifying the most effective components of each — the practice of exposing patients to the sources of their fears, for example, or examining relationship patterns. But Wampold believes that eventually these researchers will simply land, with their collection of techniques, on yet another form of therapy that proves about as effective as all the others.
The most significant difference in patient outcomes, Wampold says, almost always lies in the skills of the therapist, rather than the techniques they rely on. Hundreds of studies have shown that the strength of the patient-therapist bond — a patient’s sense of safety and alignment with the therapist on how to reach defined goals — is a powerful predictor of how likely that patient is to experience results from therapy. But what distinguishes the therapists most likely to forge those bonds is not intuitive. Wampold says that some of the attributes that would seem most salient — a therapist’s agreeability, years of training, years of experience — do not correlate at all with effectiveness of care.
To demonstrate the skills that do correlate, Timothy Anderson, director of the Psychology & Interpersonal Process Lab at Ohio University, studied groups of therapists who have been rated by patients as highly effective. He put them through a monitored exercise in which they were asked to respond to video clips featuring actors playing out difficult situations that commonly arise in therapy. “The patient might be saying, ‘This isn’t working — you can’t help me,’” Anderson says. He found that the highest-rated therapists tended, in those moments, to avoid responding with hostility or defensiveness, but instead replied with a pairing of language and tone that fostered a positive bond. “That’s displayed by the therapist saying things like, ‘We’re in this together,’” Anderson told me, “even when the patient is saying, ‘You can’t help me no matter what.’” Among the other qualities that these therapists displayed were verbal fluency — the ability to speak clearly in ways the patient could quickly grasp — along with an ability to persuade the patient and to focus on a specific problem. A certain humility in the face of the field’s uncertainties also seems to help; on a different questionnaire, therapists whose care was more successful gave responses that “reflected self-questioning about professional efficacy in treating clients.”
For the past four years, Anderson says, he has been running workshops that aim to train therapists in these various skills. “Can we do it in brief workshops?” he says. “I’m not sure that we can.” Empathy, a capacity for alliance building — these might be innate, elusive, alchemic gifts that are challenging to teach. Anderson believes that people who become therapists tend to have more of those qualities than the general population, but he also referred to a study from the 1970s suggesting that laypeople who naturally have those skills performed nearly as well in therapeutic simulations as trained therapists with Ph.D.s.
