What’s the Missing Link in Psychotherapy?

Professor Nigel MacLennan, (2021, September 7). What’s the Missing Link in Psychotherapy?. Psychreg on Psychotherapy. https://www.psychreg.org/missing-link-psychotherapy/

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Since shortly after Darwin’s world-changing book, researchers have been identifying the evolutionary links between species.  When they cannot yet show lineage, the omission is described as a ‘missing link’ until such times as the genetic bridge can be demonstrated. 

Is there a missing link equivalent in psychotherapy? If so, what is it?

There are thousands of psychotherapies; all claim to be effective. Despite the fact that they espouse using different methods, none claim to be any less effective than the others.  

How effective is psychotherapy, across the board? Get ready for a shock: there is only around a 30% success rate. Some recent figures suggest the figure is even lower – in the teens! 

Be ready for another shock: the placebo effect can be much more effective. The most effective placebos can have a 70% success rate. That is not to say that some exceptionally skilled therapists are not, frankly, brilliant. They are, and I am honoured to know several. But taking the bigger picture, for most people in need of help, psychotherapy, the evidence indicates, is no more effective than a pleasant chat over coffee with a good friend.

Why are the best therapists so effective? What are they doing that the ‘also rans’ are not?

Researchers have found that rapport and trust are central to therapeutic outcomes. The better the rapport and trust, the better the outcome. That matches placebo study findings: placebos are most effective when the recipient has the strongest rapport with, and trust in, the provider. Further, cross validation comes from studies in persuasion: people are more persuaded by those with whom they have the best rapport and highest trust.

If rapport and trust are so central to therapeutic outcomes, how are they helping? What do rapport and trust make possible?

Looking at high achievers, they are known to have strong self-rapport and self-trust. Most of us have experienced performing at an exceptional level in some area of life when we had high self-rapport and high self-trust.

There seems to be a causal connection between rapport, trust, and outcomes. What could it be? Belief.  Placebos work best when the recipient believes it will work. They believe it will work when the rapport with the provider of the placebo is strong enough to create trust.

Is that the missing link in therapy? Is all effective therapy made so by rapport, trust and belief? 

A multitude of therapeutic approaches are available, ranging from someone making listening noises while the is client lying on a couch talking for years, through to everything the client says being reflected back to them, to being encouraged to scream loudly in a sound-proofed room – too many to list.

Whatever the therapeutic rationale, if the client believes the therapy will work, will it work? If so, then all psychotherapy is a placebo. Perhaps, that is why, across the board, the efficacy of psychotherapy is about the same as a placebo – a 30% success rate.

Is that the missing link? If psychotherapy is a placebo, and all we have to do is form a rapport, gain trust, and get the client to believe the therapeutic rationale? If that is the case, the problem that brought the person to therapy is solved – until the next problem comes along. That does not sound like a long-term solution.

Some therapists do such a good job that their clients see them only once or twice, and never need therapy again for life. That doesn’t sound possible with a placebo.

Let’s look at the opposite end of the scale. Some people never wish or need therapy. They solve all of their life problems without professional help. How? Are they doing something that others are not? Are they getting effective therapy over a coffee and a chat with friends? Can they self-administer placebos? Or, is something deeper, more effective and enduring going on?

Speak to any high achiever and ask them: ‘Who was responsible for your achievement?’ Most will say something along the lines of: ‘Of course, I had a lot of help, but it was mostly down to me.’

Successful people in their billions manage life well. The problems that we all face, they cope with well. Notice the use of the word ‘well.’ We are not saying ‘easily,’ nor are we saying ‘perfectly;’ merely, well. Is the presence of whatever enables success, when it is absent, the cause of the problems that need therapy? If so, what is that factor that enables success?

‘Mostly down to me.’ What is that phrase saying? That high achievers take self-responsibility. Test that for yourself, ask as many high achievers as you can if they take responsibility for their results.

What do you think you will find if you ask people who are in need of therapy the same question? If high achievers take total self-responsibility, and those who struggle with life take less or little responsibility, it seems reasonable to think that self-responsibility is a key factor in underlying problems and therapeutic outcomes.

Could self-responsibility be the missing link; the mediating factor that explains why rapport, trust and belief are so important? Could it be that the best therapists (knowingly or otherwise) take their clients to the point of self-responsibility?

That is my belief. When I first started helping people overcome their problems, I noticed that those who made the greatest progress were those who took most responsibility for addressing their problems. Those who made no progress were those who denied or refused any responsibility.

Another observation was that once a client had reached the point of self-responsibility, almost anything worked to help the client. Why? It seemed, because they took responsibility for making it work. They successfully address their problem,  not the therapist. 

If self-responsibility is the missing link, the tipping point in therapy, the question then is, how can you take a client to the point of self-responsibility. Once you know that, the next logical question is: how can you do it quickly, systematically and reliably?

Those were the questions I asked that led to the creation of the methods that were, many years later, documented in the book SRT – Self-responsibility Therapy.

Is self-responsibility (SR) the missing link in psychotherapy? Does psychotherapy work when the client reaches the point of SR? Do clients make themselves better after they take SR? 

If so, at last, we have a scientifically testable therapy approach. We test levels of SR before and after therapy. We can compare progress to the changes in levels of SR. We can evaluate whether people with the highest levels of SR are more or less likely to need therapy. We can study the relationship between how high a level of SR a person reaches and whether they need no or little further help. We can determine how the level of SR in the therapist determines the outcomes of therapy.

Have we ever had such a scientifically testable approach to therapy before? If SR is the missing link in psychotherapy, we can now improve and modify many existing therapies to incorporate self-responsibility.


Professor Nigel MacLennan is a consultant at London Metropolitan University. He tweets @nigelmaclennan


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