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Exploring the importance of the psychotherapeutic relationship.
This is the first of what will be a series of weekly blogs drawn from our podcast of the same topic and covering the most crucial questions of psychotherapy. We think it will be useful across all clinical disciplines, for practitioners, trainees, patients, and families.
1n 1936, Saul Rosenzweig, PhD, had the brilliant intuition that the "common factors" across the various types of psychotherapy may be more important to successful outcomes than the specific techniques that distinguish them. He cleverly called this the "Dodo Bird Verdict" after Dodo's famous quote in Alice in Wonderland, "Everyone has won, and all must have prizes."
Nine decades have passed, allowing time for hundreds of controlled studies and dozens of meta-analyses, but controversy still roils regarding the relative strength of the specific versus the nonspecific factors in promoting psychotherapeutic change.
Two conclusions seem clear:
1. A good therapy relationship is necessary to good outcome—but not always sufficient; and
2. Specific techniques are most differentially helpful when treating specific symptoms or behaviors (eg, anxiety, eating, or borderline personality disorders).
The beautiful 1961 book Persuasion and Healing by Jerome Frank, MD, PhD, gave the best description of common factors in psychotherapy and traced them to the ancient rituals practiced by shamen and shawomen.
Shaman and patient develop a powerful relationship. They share the belief that the shaman has special powers to heal the patient, and both have high expectations of success. The shaman allows the patient to enter a magic circle of healing and performs magic healing rituals. As a result, the patient develops insights into the causes and cures of his problems and has a corrective emotional experience, and the symptoms disappear. The patient then reenters the everyday world, healed and renewed.
It is no coincidence that modern psychotherapy so closely resembles ancient shamanic practice. Human nature is remarkably stable—what worked 50,000 years ago still works today. Expectation of symptom relief and reversal of demoralization (plus regression to the mean via tincture of time) remain very powerful drivers of change.
But modern psychotherapy also differs markedly from shamanic practice in its secular belief system: reliance on the methods of science and the development of specific, effective, and empirically supported techniques.
Every therapist should be highly skilled in establishing and maintaining powerfully healing psychotherapeutic relationships with a wide variety of patients. Every therapist should also have a toolkit of specific psychotherapeutic techniques and the wisdom to know when to use which technique with which patient. Therapists who rely only on the relation or only on the techniques restrict their therapeutic range and shortchange their patients.
This brings up the interesting question of how the therapeutic relationship is similar to, but also different from, all other human relationships.
The similarities are obvious and pervasive. The therapist/patient relationship is just a special case of all human relations and the principles that apply to them mostly apply to it. Therapists who are good at relating to others tend to be good at relating to patients. Therapists who are bad at relating to people tend to be bad therapists. Patients who relate well in life tend to relate well in therapy and are considered easy patients. Patients who relate poorly to others in life are the ones who most need us and most teach us, even if they are considered difficult patients.
The therapy relationship also differs markedly from most other interpersonal relationships in ways that we will detail in our next blog. (Spoiler: It is more intimate, less selfish, more mutually helpful, and more assisted by high expectations and effective techniques).
Dr Frances is professor and chair emeritus in the department of psychiatry at Duke University. Dr Goldfried is distinguished professor in the psychology department at Stony Brook University. Find them on Twitter @AllenFrancesMD and @GoldfriedMarvin.