Which really helps

“Just because studies show that an intervention works, we don’t automatically know what exactly works and why,” says Wolfgang Lutz, psychotherapy researcher and professor at the University of Trier. It is often simply assumed that the processes that behavioral therapy or psychodynamic theory postulate are at work. However, the evidence What in psychotherapy helps to achieve much more difficult than that, that she helps.

The American psychologist Saul Rosenzweig (1907–2004) first expressed the idea that all therapies work through common factors in 1936. As he observed, different methods led to similar results. Therefore, he assumed that they probably help through elements that are common to all. He used a quote from Lewis Carroll’s book Alice in Wonderland, in which the bird Dodo suddenly announces the end of a race and states: “Everyone has won, and everyone must have prizes.” This so-called “Dodo Bird Verdict” that all approaches have comparable effects and do not differ significantly from one another has become the subject of heated debate in psychotherapy. In fact, the differences in effect sizes between the forms of therapy are rather small. Does it then matter which of these a patient receives?

“The dodo bird verdict is sometimes misunderstood,” says Flückiger. »It’s not at all the case that all psychotherapy would help equally well. There are many variations. Some work, others don’t. On average, however, they seem surprisingly robust.« The Dodo Bird Verdict can only make statements about processes that have been scientifically examined. “What it actually says: The variability of success within a therapy school is higher than between schools. So the therapy directions don’t explain a great deal about the outcome variance.« Or in other words: the differences inside a therapy school are bigger than that in between Schools. But that doesn’t mean that it doesn’t matter what the practitioner does.

“Just because studies show that an intervention works, we don’t automatically know what exactly works and why.”(Wolfgang Lutz, psychotherapy researcher)

emphasize similarities

General effective factors occur in every form of psychotherapy and, in comparison to specific ones, are not part of the technique that a therapist has learned in the course of his training. Examples of such components that cross all disorders and therapy schools are the patient’s willingness to change and the quality of the relationship between him and the therapist. No one seriously disputes that general factors work in psychotherapy. But what is your share of the success? Many experts now believe that the role of specific components has been overestimated – and common elements are more crucial. “The conflict between schools can be overcome through the idea of ​​general factors,” Flückiger believes. He considers school thinking to be an outdated construction anyway.

Video recordings of treatments show that in some cases very similar things are being done – even across therapy schools. “Different psychotherapies in Germany are much more similar to each other than cognitive behavioral therapy in the USA and in Germany,” he explains. An example is duration. In Germany up to 40 paid sessions are common, in the USA the therapies are shorter because the patients usually pay for them themselves. This also has an impact on how the therapy is designed.

Flückiger researches, among other things, the working alliance. The term describes the quality of the collaboration between therapist and patient, i.e. how much both agree on the goals of the treatment, how well they work together and how much they trust each other. With hundreds of studies, the working alliance is considered the most intensively researched general effect factor – and can predict the success of a therapy most reliably.

“The therapeutic relationship is an important but massively overestimated factor,” says Margraf instead. In his view, the best documented mechanisms are learning and memory processes. If you ask patients what helped them, the relationship with the therapist is hardly ever mentioned. »After a good therapy they should say: I had a problem, but I got over it. I got help, but I’m the one who made it.” Flückiger counters: “The relationship doesn’t say everything, but it also doesn’t say nothing. It is the most robust predictor of treatment success that we know of to date.”

However, it is not the case that one can say: If the therapy relationship is good, then everything is fine, he emphasizes. In psychology, nothing is ever black or white. “We’re talking about explained variances of around eight percent.” This means that around eight percent of the differences in success between therapists can be attributed to their ability to build good working alliances. “Some do it a little better than others. And also have better therapeutic success.

What distinguishes successful therapists?

Skills such as empathy, warmth, mindfulness, and resilience also seem to play a role, as well as how therapists focus on the problem, convey hope, and how convincingly they present themselves. In addition, recent findings suggest that it is helpful if they critically question their actions.

Other circumstances also influence the practitioner’s success. “Imagine that the therapist is in the middle of a divorce, then he may not have the resources to respond to every patient,” says Flückiger. Another factor seems to be the number of patients and the location of the practice, such as whether it is in a poorer neighborhood. “These are all conglomerates that are relatively difficult to separate,” he explains.

According to Margraf, there are clear indications that everything that activates the patient and gives him hope for improvement is important. In addition, one must differentiate according to individual fault areas. With depression you can do anything – and everything helps somehow. Then there are disorders like anorexia, in which unfortunately psychotherapy is not particularly successful overall. Whereas in the case of anxiety, confrontation is clearly a crucial mechanism. He is currently trying to find out what exactly works. In addition, he conducts experiments to examine the importance of self-efficacy. For example, extinction learning (the active relearning of a physiological fear reaction) works better if, before the confrontation, one remembers three moments in life in which one mastered a major challenge.

John Norcross from the University of Scranton (USA), together with colleagues, discovered other active principles that proved to be significant in meta-analyses, such as the willingness of those affected to change and regular feedback. If you let patients and therapists predict whether the treatment will help, it turns out that patients are relatively good at it, therapists are not – they overestimate their success. However, if the therapist receives regular feedback, the effectiveness increases. “It’s important that both get feedback session after session on how the therapy is developing,” says Flückiger. Such instruments for quality assurance are used across the board in Great Britain, but there is still room for improvement in Germany.

“Psychotherapy research is very self-critical,” he says. »Sometimes this is misunderstood, and the discourses between psychotherapy researchers are perceived as disagreement.« He experiences this as something very positive. It is a sign of quality assurance that such open debates are being held.