The number of Americans receiving mental health care is rising. In 2020, the percentage of adults ages 18 to 44 receiving treatment was 23.2%, according to a National Center for Health Statistics brief, compared to 2004, when the number of adults seeking mental health care was just 13%. Now mental health care is a long contentious, often overlooked, and habitually underinvested area. But if collectively, more people are now investing time, resources, and energy in therapy, it behooves us to try to better understand what makes for a successful therapy outcome.
In this post, I want to talk about one key predictor of a successful therapy outcome: the trust between the therapist and the client. More than the specific modality of therapy used, or technical interventions employed, or even the years of experience the therapist has, research shows that the key to success lies in the quality of the client-therapist relationship, which in turn creates hope and expectancy for a positive change. A conclusion of the Third Interdivisional American Psychological Association Task Force on Evidence-Based Relationships and Responsiveness makes this clear: “The therapy relationship accounts for client improvement (or lack of improvement) as much as, and probably more than, the particular treatment method.”
So what exactly underpins a solid relationship of trust between a therapist and client? In a context as particular as that of psychotherapy, where essentially two strangers come together and share intensely intimate information on the premise of complete confidentiality, exactly what makes one therapeutic relationship more effective than the next one?
The importance of the first encounter
First, the therapist must be mindful of the critical importance of the first meeting with the client, because the premature drop-out rate is highest after the first session than at any other point. In the initial meeting, the therapist must understand that the client is very quickly trying to ascertain whether the therapist is worthy of their trust, possesses the necessary expertise to help them, and whether the therapist will take the time and effort to understand not only the problem they are coming in with but the context in which the problem is presenting. An interesting piece of trivia is that humans apparently make very rapid determination, within 100 milliseconds, based on viewing someone’s face, of whether that person is trustworthy. What that means is that likely the client is making very rapid judgments based on details like how the therapist is dressed, the decor of the room, and other features of the therapeutic setting. This, combined with a client’s preconceived notions about the nature of psychotherapy, culminates in the overall impression that a client walks away with from the first session - and determines whether a therapeutic relationship can ensue from this first meeting.
Perception of genuineness, sense of self-efficacy, and collaboration are also key
Once the initial therapeutic relationship is established, the next critical element is how much the client and therapist perceive one another to be genuine. The importance of genuine human connection is widely recognized. When done right, psychotherapy allows for a human connection with a caring and empathetic individual, which is in and of itself health-promoting, especially for a client who otherwise would not have such a connection. Secondly, it is critical that a client feels that they have an explanation for their difficulties that are in their power to overcome or cope with. If they are presented with an explanation but are made to feel they are powerless in the face of it, there is no therapeutic work to be done. This also means that the client and therapist must be in agreement about the goals of therapy as well as the necessary therapeutic tasks, so that there is a sense that they are both engaged in “collaborative, purposive work.” This then, importantly, has the effect of increasing the client’s confidence and expectations that the treatment will be effective. Then, once there is trust in the therapy process and in the therapist, the specific health-promoting tasks of the therapy can finally be induced, whether that is modifying maladaptive ways of viewing the world, understanding dysfunctional patterns so they can be approached differently, gaining self-insight, or learning to accept oneself, to name a few.
The “person of the therapist” also makes a difference
Furthermore - and not surprisingly from everything discussed just now - it has been observed that the person of the therapist makes a difference, too. Research indicates that things like the therapist’s interpersonal skills, persuasion, warmth, and sometimes even charisma matter. We’ve all probably experienced that good bedside manners in a physician can make an impact on our overall experience when receiving treatment in a medical setting. Still, a course of antibiotics prescribed by a cold physician ultimately does not differ too much from the same course of antibiotics prescribed by a warm and compassionate physician. But in the psychotherapeutic context, it makes a tangible difference in the treatment outcome. Think about it: if a therapist barely took the time to listen to you and lacked empathy, even if this therapist had the same treatment plan as that of another therapist, who carefully listened to you and took the time to cultivate trust with you, would you feel inclined to do the therapeutic work to follow it? Simply put, delivery matters in therapy. And by the way, data shows that no significant difference is observed whether the therapy is conducted virtually or face-to-face in terms of the trust that can be built between a therapist and client. This is encouraging in the era of teletherapy, which has made therapy more accessible to a wider array of populations, including those living in rural areas who otherwise may not have access to mental health care or those who lack the means or time to commute to a physical office.
Client-therapist fit is critical - so don’t compromise on that
So what does this all mean for you if you are searching for a therapist? Don’t compromise when it comes to a good fit with your therapist, because everything else follows from this client-therapist relationship. Assess how you feel in your initial interactions with a prospective therapist, whether that’s during an initial consultation or even in email exchanges. It doesn’t mean you need to nitpick, but pay attention to how you feel and ask yourself: do I feel comfortable? Hopeful about the prospect of working together with this therapist? If you don’t feel comfortable when talking to your therapist or you don’t feel heard or seen, there is no shame in seeking out someone else who feels like a better fit. In my private practice, I make it a point to offer a free initial consultation for this very purpose. Working with a client in one of their most private and vulnerable moments is a privilege that must be earned - so I don’t assume that I will necessarily be a fit for everyone. So be a discerning consumer - your mental health is certainly worth it.
Comments