Heart and Soul of Change
Heart and Soul of Change
(July 20, 2002)
A recent conference here in Toronto (The Heart and Soul of Change) has provoked numerous discussions regarding the notion of what "works" as far as psychotherapeutic change goes. The surprising thing to many therapists has been the fact that no particular model or theoretical backdrop is any more effective than any other. This from countless studies over the last couple of decades. While this is humbling to many who have stood fast to their training and orientation, it does suggest something more important. The authors (and editors) Mark Hubble, Barry Duncan and Scott Miller have outlined these pantheoretical or "common factors" in their book The Heart and Soul of Change.
This comprehensive volume lays out the common factors, their theoretical and empirical background as well as specific cases and contexts for their application. The voluminous research they cite has yielded four general factors which must be involved in any kind of therapeutic change. The most surprising factor (for some) comes from the clients themselves: their life situation, their support systems, their innate strengths. The next factor in importance is the relationship with the therapist. These two alone, according to the research, make up 70% of what leads to significant therapeutic change. The remaining 30% is made up of equal measures of the placebo effect (read hope) and theoretical/technical factors.
One of the most striking ways these factors are interpreted (especially the first) in this book is an engagement with clients in a discussion about how they see change happening in their lives and what it might take to achieve it. This may seem obvious or at least intuitively sound to most therapists, yet many clients in my and others' experience, come to therapy expecting to be told what to do in order to change. To embark on a conversation where the client marshalls their own resources and ideas about change would seem a radical departure from many therapeutic models.
The remaining chapters of this book are a rich exploration of the four common factors. In the final section there is a critical look at the trend towards medicalization and pathologizing of human behaviour under the rubric of providing "safe and effective treatments" - ie the unholy alliance in the United States between the Diagnostic and Statistical Manual of Mental Disorders (DSM), and the HMO's (insurance companies). We in Canada are not far behind. This despite the evidence that psychotropic medication is no more, if not less, effective than psychotherapy for many diagnoses, and certainly not effective at all if not done in tandem with psychotherapy. There is also considerable evidence (also cited by the authors) that a diagnosis (ie a DSM diagnosis) is not at all necessary for a successful psychotherapy.
Two questions, however, seem to beg: what is psychotherapy anyway? And: what is "change"? Since these are the two most salient terms involved it seems relevant that they be defined. And they are both defined somewhat differently by the various models and theories of psychotherapy. A psychoanalytically trained therapist would define psychotherapy as perhaps a transferential relationship whereby the unconscious enactments of the client are made conscious, and thus more under the control of the client leading to a change in behaviour towards a more satisfying way of living. A Jungian therapist might see therapy as a long-term individuation process involving a reconciliation of various archetypal positions within the psyche. The end result: a satisfying life. A cognitive-behavioural therapist might describe it as a forum for altering dysfunctional thought patterns and their resultant behaviours leading to more stable mood states. Again, a more satisfying life might be the result.
It seems to me that underlying all of this is an assumption that creeps perilously close to a most philosophical question: what is a satisfying (read happy) life? Have we, as therapists, answered that question? Some might think so. Is that what change is for? Perhaps the authors are addressing the vexing quality of this problem by stressing the client's ideas of what change might look like and what it might take to achieve it. But, as Adam Phillips points out in The Beast in the Nursery (one of Caversham's favorite books), maybe happiness is not the goal at all, but the acceptance of the inevitable disappointments from crib to boardroom, from raw desire to adult compromise. What I do think in all of this is that therapists shouldn't presume to know too much about what their clients need, nor assume that they know what change might be, apart from inevitable. - posted by Eric
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