Successful and Less Successful Psychotherapies Compared

What is it about?

This study aimed to explore contrasting cases of successful and less successful psychotherapies conducted by three therapists. Comparing the patients’ and the therapists’ accounts of their therapy experiences, we found both differences and similarities, both between the contrasting cases and between the therapists, indicating the uniqueness of the therapeutic interactions and the multitude of factors influencing the therapy process in a complex, synergistic, and mutually reinforcing manner. Nevertheless, the main differences were already manifest at the outset of treatment. In the successful cases, the therapists gave an elaborate picture of their patients’ problems and background, consistent with the patients’ presentations. In less successful cases, the therapists misinterpreted or disregarded some aspects that the patient described as important and could present an unclear image. Consequently, in the successful therapies, both parties were more in accord about what would be helpful. From the outset of treatment, the therapists could flexibly adapt their therapeutic stance to their patients’ expectations, needs, and capacities. All the patients in the successful cases overtly expressed their fears, inner barriers, or determination to make an effort. This was not found in the less successful cases, and the therapists seemed unable to establish a sustainable sense of mutual collaboration. A further contribution to effective processes in successful cases was early staging of the patient’s problems, or a crisis in their relationship, followed by repair of collaboration. This was not reported in the less successful cases.

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Why is it important?

The present study might have important implications for clinical practice and psychotherapy training. Looking for within-therapist effects, we found both effective and ineffective therapeutic dyads. Our findings suggest that the therapist’s expertise has to be viewed as “case-dependent.” In order to prevent suboptimal outcomes, the therapists have to be observant of cases when they, from the beginning, have difficulties in conceptualizing the patient’s problems and their ideas of the coming therapeutic work. Scrutinizing their own and their patients’ way of being together might be more difficult but especially important early in therapy. Negotiating both participants’ ideas of therapeutic goals and tasks might in itself be a mechanism of change. Ongoing metacommunication with the patient about what is going on in the therapeutic relationship might enable therapeutic impasses to be worked through and could prevent unsuccessful treatments. In order to find the right interventions, the therapist has to continuously assess the patient’s functioning and be open to reconsidering the initial assessment of the patient’s problematic areas and capabilities. Our study indicates that an important ingredient in psychotherapy training might be guidance on how to balance support and challenge in the therapeutic process and how to adjust to the patient’s needs and relational patterns. This includes training in being attentive to and making active use of the therapist’s positive as well as negative countertransference. Furthermore, continuing education has to implement the implications of current research on the therapists’ contributions to negative processes. Even the most skilled therapists can learn much from their least successful cases and their own treatment failures. It is incumbent upon the therapist to differentiate between the therapist’s and the patient’s wishes, fears, and reactions. Doing so involves the therapist intentionally bringing to mind personal experiences that somehow relate to the patient’s suffering, before responding with an exploration of what the patient cannot contain. The therapist’s response has to be “marked” by the difference between the patient’s and the therapist’s perspective, thus making possible a “third position.” Such a position includes alternating between participation in the patient’s inner world and observation, starting with the self and going to the patient.