Psychotherapy in the 21^st Century: Reflecting on the Importance of Relationships

In general, people seeing a therapist are better off than those who do not seek treatment or on waitlists; the results of numerous studies consistently reveal those receiving therapy are better off than those on waitlists or not receiving treatment with effect sizes ranging between 0.8 and 1.2 [1-5]. Simply stated, psychotherapy works. However, results of recent studies suggest that psychological treatments have not significantly improved over the last four decades [6]. Although not extensively discussed, the failure to address dropouts in psychotherapy is one of the biggest challenges facing our field. Research to date suggests that premature termination or dropout averages about 47% [7]; for children and adolescents, the range varies from 28% to 85% [8- 9]. Moreover, results of outcome research also reveal the following alarming statistics:

1. A significant percentage (30% to 50%) of clients do not benefit from therapy [2,10].

2. Deterioration rates among adult client’s range between 12% and 20% [11].

3. It is estimated that the clients who do not benefit or deteriorate while in psychotherapy are responsible for 60-70% of the total expenditures in the health care system [6].

Perhaps most importantly, clinicians fail to identify those clients not progressing, deteriorating, or at risk for dropping out of treatment (Hannan et al., 2005). Thus, the challenge for the field and researchers alike is to better understand why we have not been able to improve on existing models and treatment conceptualizations to develop new paradigms for helping clients. The purpose of this commentary is to describe possible reasons for the lack of improvement based on our clinical and research experiences and provide recommendations for re-thinking points of emphasis in the therapeutic process.

Perhaps the stagnation of outcomes is related to the failure of the field to adapt to societal changes over time. The changing configuration of families has had tremendous implications for individuals and families as well as the therapists working with these clients. Two-parents working, single-parent families, same sex parents, and grandparents filling the role of primary caregivers have become increasingly common, with each creating its own unique challenges for family members and therapists in terms of engaging clients into treatment. In addition, the increased (and often excessive) use of technology has had unintended negative consequences on the development of socialization skills and resulted in increasing isolation and withdrawal, especially among children and adolescents. Moreover, increasingly more numbers of children and adolescents are reporting anxiety and depression, which may be in part be related to stressful home environments, increased standards and demands at school, and unhealthy uses of social media.

Taken as a whole, perhaps these factors speak to a larger issue-a lack of meaningful connection with others. Psychotherapy has become more mainstream and accessible which is very encouraging; however, in some cases, it may also serve as a proxy for human connection. Many clients present without a clear focus and struggle to develop specific goals yet report that therapy is helpful or effective. Given the changing motivations for seeking help, it is imperative that therapists consistently reflect on their work and whether it is truly effective in a therapeutic and clinically significant sense. Unfortunately, many therapists are content to take a passive role in which clients can come in each week and discuss significant events since the last session with little to no emphasis on growth or change. Perhaps these therapists also do not push or challenge these types of clients out of comfort-it’s easy to listen and validate for 45-50 minutes; many clients may also use this “chitchat” approach to avoid more sensitive or uncomfortable topics. However, the challenge is that there is no road map for the progress or how to define success, which results in people being in treatment longer than necessary and often a drain on resources which might otherwise be allocated towards clients with more severe issues or concerns. Furthermore, this also presents an ethical dilemma for the clinician who may like keeping the person on his or her caseload because it’s an easy clinical hour and consistent money, but not entirely in the client’s best interest if the benefit is little or none.

We contend that there must be renewed emphasis on the power of the relationship and human connection while also developing clear and explicit plans for shifting relationship-building skills developed in the micro of the counseling relationship to the macro of everyday life and plans to translate skills learned into other settings and relationships. While a strong therapeutic bond is necessary, it is not enough; thus, there is a need for accountability to ensure growth and meaningful change-from the client’s perspective.

More recently, funding sources and payors have advocated for the use of evidence-based treatment approaches; however, many of these treatments neglect to take into consideration the societal changes discussed above; specifically, the power of human connection for mental wellbeing. In fact, it might be argued that the near exclusive emphasis on specific models and techniques has come at the expense of the therapeutic relationship, especially in those cases in which the approach is inconsistent with the client’s goals, objectives, or personal change process. This treatmentmismatch likely contributes to premature dropout or lack of progress in therapy and is reflected in the lack of improvement in psychotherapy outcomes over the past four decades. Practitioners may need to re-think the therapy process and what really makes a difference in terms of personal growth and change. While the specific therapeutic ingredients (agreement on goals, tasks, and methods; model, technique; hope; commitment to the process) may not change, perhaps it is the amount of emphasis placed on each of these components which requires reconsideration along with a willingness to reflect on progress on an ongoing basis which will yield the greatest results. We argue that the therapeutic relationship is the foundation for success in therapy and must be monitored and continuously reviewed to identify ruptures in the alliance (e.g., disagreement on goals, not feeling heard, validated, understood by the therapist) before they lead to premature dropout – even at the expense of models and techniques. Most clients will not tell their therapist when things are not improving; in fact, they will likely schedule the next appointment and then cancel or no-show. Consequently, creating a culture of accountability and feedback to assess the strength of the relationship and monitor progress is essential for improving retention and treatment outcome.

None.

No conflict of interest.

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