How vs Who

For those of us who are considering seeking help from a therapist, the idea of being transparent with a stranger may cause as much stress as the problems we seek to solve. The commitment to therapy involves some emotional discomfort, as well as time and money. We try to imagine a person who may be able to understand us when friends and family, despite good intentions, have injected too much of their own emotional baggage into this dialogue. Friends and family want to help us, but they’re part of our ecosystem. They have skin in the game. We try to imagine what a counselor could say or do that we haven’t thought about already.

An often-cited study by Asay and Lambert from 1999 suggests that the quality of the relationship with the therapist may account for as much as 30% of therapeutic efficacy, while the counseling technique or modality may account for as little as 15% of therapeutic efficacy (see accompanying pie chart). There have been other studies over the last 50 years that have yielded similar conclusions. There are yet other studies that have demonstrated that the whole dynamic around therapy and its efficacy are very nuanced and it’s hard to say what’s going on there.

There’s a concept in research that the more relevant something is to real life, the harder it is study. For example, you can drop a ball and get really good measurements of how long it takes to hit the ground. You can draw conclusions from that. The problem is that nobody cares about the ball. As humans, by definition, we face this existential crisis of who we are and what we’re supposed to do. In wealthier countries, where food, clothing, and shelter are in place for most people, the issues of existence, happiness, purpose, what you’re supposed to do with your life, become paramount. This ain’t no bouncing ball.

Money is the driving force behind healthcare, like it is for most everything else in America. For-profit, and non-profit, healthcare entities don’t want to waste their money, either because shareholders need profit, or non-profits need to try to help as many people as possible with the funds they have. When managed care came on strong 30 years ago, the financial incentive toward brief therapy-or pills instead of therapy-became much stronger. Researchers have a lot of incentive to come up with a game changing treatment in terms of advancing their academic or professional careers. There is financial incentive for an entity that maintains a proprietary interest in a mode of treatment. The treatment becomes essentially their intellectual property. Managed care would rather spend money on a quantifiable type of treatment than on a relationship. The relationship may be a more relevant factor, but how do you quantify it?

12-Step, once the whipping boy of behavioral health academics, is now being shown by some recent research as being equally effective, or equally ineffective, as all the other approaches to addressing substance abuse. 12-Step is free, in every neighborhood, and is all volunteers, addicts helping addicts. But nobody knows how it works.

With all these evidence-based treatments out there, it seems like people would be happier, that we wouldn’t be in the middle of an opioid epidemic that has no end in sight. At this point, most of us know a family that has pain or loss driven by opioid addiction. Coincidentally, the opioid epidemic is believed to have been created by a company with a financial incentive to show, through research, that opioids were an evidence-based and inexpensive treatment for all sorts of problems.

Outside of the substance abuse realm, the demand for plain old counseling is through the roof. There is a lot of mental illness out there these days. Given how many real problems there are in the world, maybe “mental illness” is the wrong term. It may be rational to be troubled, worried, overwhelmed.

We should continue to seek treatments that work efficiently. However, for the person on the street who is feeling persistent emotional pain, there is strong evidence that, instead of seeking a certain type of therapy, it may be more productive to seek a certain relationship with a therapist. “Do I feel comfortable around this counselor? Do they seem to actually care and want me to do well? Can I be myself around this therapist? Are they warm? Do I actually like them? Do they utilize plain talk and common sense?” may be the most relevant questions when we are seeking to feel better. Maybe it’s better to ask “Who?” than “How?”

All that being said, Asay and Lambert also concluded that “client variables and extra-therapeutic events” may account for as much as 40% of the healing process. Any relationship is a two-way street, so a client’s pre-existing ability to form and develop relationships could be as much as half of this “therapeutic relationship” thing that’s supposed to be worth 30%. This 40% category also includes things like the client’s personality, their motivation to get help, what their family was like growing up, their education, attractiveness, their luck, things that make behavioral health research really complicated.

When you’re a kid, it seems like the adults have everything under control. When you become an adult you realize there’s a lot of “wingin’ it” in life, improvising in the moment. Humans, to have made it this far, are capable of making a lot of judgements very quickly, without taking time to consciously consider all the factors in play. When a woolly mammoth is charging at you, you probably ought to trust your gut vs trying to call a time-out to consider your next move. Most of the time doing what feels right works out better than what’s supposed to be right.