Therapy works. There’s no doubt about that. The data is overwhelmingly positive. There’s no shortage of evidence-based treatments, meaning that their efficacy has been clinically and scientifically verified. But the technical part of therapy is only half of the story.
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We also know that therapy doesn’t work for everyone. Much attention has been paid to techniques, treatments, and therapist qualities. However, less attention has been given to perhaps the most important factor of all: the client. The client is the reason for the engagement and the focus of the process. But the therapeutic experience is unique to each person. Things like expectations, commitment, and engagement vary from person to person. Just how these factors affect the person’s experience with therapy and the chances of successful treatment.
Recent attention has shifted from the technical aspects of therapy to a more client-centered focus to better understand how a client’s experience and approach to therapy can influence the process. What can we learn about therapy from the client’s perspective to improve outcomes? Two key areas that seem to be critical to the success of therapy are client autonomy and motivation.
Client autonomy is in essence, the principle of independence, and a fancy way of saying the client has freedom of choice and action. It is a guiding principle of ethical and client-centered therapy. And, it’s a powerful factor in a client’s engagement in therapy.
When someone comes to therapy, they are often hesitant and unsure, looking to the therapist for guidance. Therapy is based on the therapist-client relationship. In fact, the quality of this relationship has been consistently shown to be the strongest predictor of whether or not therapy is successful. This holds true when looked at from both the client and the therapist's perspective. However, one of the most common misconceptions is that the therapist is somehow an “advice giver” or will “tell me what to do”. In reality, the client is the actual stakeholder in therapy. It is the client who is the decision-maker and change agent. The therapist is there to help them through that process of discovery and change.
Why someone comes to therapy matters. Self-determination theory tells us that people want to feel as though they are in control of their situation, that they have a degree of autonomy. People come to therapy sometimes by choice, but sometimes by mandate or some external pressure, as in “I’m going because I have to”. Not surprisingly, these clients are likely to be far less inclined to engage than clients who come to therapy feeling more in control. This sense of control has been found to significantly impact engagement, effort, and motivation. In short, people who were more autonomously motivated have better treatment outcomes.
Honestly, people only do what they are motivated to do. Therapy takes work. And time. Motivation is what propels change and is the key to long-lasting change and success in therapy. What is it that not only prompts someone to start therapy but keeps them motivated, especially when the hard parts come? With the shift to a more client-focused approach to therapy, studies have looked at a few of the key motivators associated with successful therapy.
Certainly, feeling in control is one factor in motivation. In fact, client autonomy and its link to motivation have become a focus of research on self-determination and client-focused practices.
Hope is a key motivator for many. After all, if there’s no hope for change, why try? Being hopeful for success has been linked to greater motivation and more positive treatment outcomes.
Psychological mindedness or being able to be self-reflective, insightful, and introspective is motivating. It increases over time in therapy and can yield new ways of thinking and responding.
Having positive and realistic expectations has been mentioned as motivation and is a staple of goal achievement.
The power of the therapeutic alliance cannot be discounted in motivation. Having that trusting connection allows someone to feel safe to explore.
Researchers acknowledge that these are a few of the many, many possible motivators. How do you know what motivates someone? Ask them.
Clients sometimes think that they are merely participants and that therapy is the job of the therapist. In fact, client-focused therapy recognizes the client’s unique contributions to the therapeutic process. Far from a passive participant, the client is an active participant in the process and its progress. So, if you’re a client, how can you support the process?
Be open - Honesty and transparency are key to success. A therapist can only know what their client shares. To understand your needs, the therapist needs to know your struggles. It’s even important to know what your preferences are for therapy and it’s ok to share that too. It’s your therapy.
Do Your Work – Merely “talking about it”, or learning skills isn’t enough. You have to learn to use those new skills. If your therapist gives you “homework”, it’s not busy work. It is your opportunity to practice new skills. You will find some that work and some that don’t. The feedback you come back to the session with is critical to finding your best solutions.
Engage – Therapy is like a conversation. Sharing information. It’s normal, especially early on, to want to protect your feelings. After all, you’ve learned to guard yourself against pain. Challenge yourself to go beyond “yes”, “no”, or “I don’t know.” The “how” and “why” things happen to yield important clues to your unique experience.
Show Up – This may sound overly simple but therapy can’t help you if don’t go.
Give it time – You didn’t get to this place overnight. Healing and change take time. Give yourself the gift of time to make the changes you want to make. The time will pass anyway. Why not use it to heal?
Find what motivates you – What keeps you working when times get tough? There will be hard things that come up in therapy. It’s tempting to quit. When those times come, think about why you started. Envision your goals and allow yourself to trust the process.
While we don’t know all of the ins and outs of just how and why therapy works, we do know that it’s more than just “the therapy”. The client brings a unique and powerful influence to the process. Client-focused therapy brings the strength of both together.
1. Fuertes, J. N., & Williams, e. N. (2017). Client-Focused Psychotherapy Research. Journal of Counseling Psychology, 64(4), 369-375. Retrieved from http://dx.doi.org/10.1037/cou0000214
2. Forester-Miller, H., & Davis, T. (1996). A Practitioner's Guide to Ethical Decision Making. Retrieved from American Counseling Association website: https://www.counseling.org/docs/ethics/practitioners_guide.pdf
3. Horvath, A. O. (2001). The alliance. Psychotherapy: Theory, Research, Practice, Training, 38(4), 365–372. https://doi.org/10.1037/0033-322.214.171.1245
4. Ryan, R. M., & Deci, E. L. (2008). A self-determination theory approach to psychotherapy: The motivational basis for effective change. Canadian Psychology/Psychologie canadienne, 49(3), 186-193. doi:10.1037/a0012753
5. Michalak, J., Klappheck, M. A., & Kosfelder, J. (2004). Personal goals of psychotherapy patients: The intensity and the “why” of goal-motivated behavior and their implications for the therapeutic process. Psychotherapy Research, 14, 193–209. http://dx.doi.org/10.1093/ptr/kph017