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It’s The Relationship That Heals

July 11, 2013

The small, nonprofit mental health agency I contract with is doing more Medicaid billing these days. Reading supposed “clinical literature” about current requirements and guidelines for documentation, from that (and various other sources), I just feel overwhelmed with institutional rhetoric about the “mental health industry” (sic) and “industry standards,” ‘behavioral health, “behavioral medicine” and “evidence-based treatment strategies.”

All but the last of those terms grate on my nerves. “Industry”? Are we providing psychotherapy, counseling, and case management to troubled people with many problems and very limited resources—or modeling ourselves after a steel foundry? What’s next—“Industrial-Strength Mental Health”?
But I have nothing against evidence, research, and outcome studies at all.

However, a simple-minded application of the term “evidence-based treatment strategies” is often used crudely, especially by administrators who are not therapists themselves, to hit therapists over the head if they do not follow a cookie-cutter standardized procedure, like a recipe out of a cookbook. Many administrators chose that career direction upon finding out they were no good at doing therapy. “So-called psychotherapy is easy,” some of them have said. “Ya just let people ventilate, get it all off their chest, then ya give ‘em common-sense advice. Anybody can do that.”

There is just a little more to it than that.

I said I respect well-designed research, evidence, and outcome studies. Here is the single most-evidence based, research supported statement anyone can make about successful psychotherapy and counseling:

It’s the relationship that heals

This is real back-to-basics bedrock reality, confirmed repeatedly over decades by outcome research: the quality of the therapeutic alliance (marked by compassion, acceptance, clarity, empathy, attunement, etc.) is more determinative of outcome than the school of thought the therapist belongs to or the approach or techniques used. Its importance can hardly be overstated.
Significantly, the most “hard-nosed” reality is humanistic, uniquely personal, and steeped in subjectivity.

Psychotherapy is certainly and art and has no necessary conflict with science. But if it is a science, I believe it is a science of subjectivity. The focus is on the client’s subjective experience. And every person is different, is unique.

This presents special challenges for scientific researchers who want everything to be objective and impersonal and who sometimes disparage whatever is subjective and personal. That doesn’t mean research if futile but it has to be adapted.

Analyses, strategies, approaches, and techniques certainly have their place but again and again we have to turn back to basics: it’s the relationship that heals. When therapy takes a long time or progress is stalled, the difficulty is usually located in the therapeutic relationship. The two people are not on the same page, not attuned, now focusing on the same goal, or there is problem with building and sustaining trust.

Whenever I find myself thinking “I don’t know what to say in response right now,” I tell myself, “shut up and listen.” Listen as attentively, carefully, and compassionately as I can and the appropriate thing to say in response will come to me.

I find solace in affirming the validity of the subjective experience and remembering that some things cannot be reduced to the impersonal or the objective. “Do your ‘research’ into understanding the patient,” Richard Chessick wrote, “and the therapy will take care of itself”

These are the basics I keep going back to. Perhaps that makes me an old dinosaur but they are solidly “evidence-based.”
There is a lot more to it than that, but this is the bedrock foundation, I believe.

Thanks for reading.

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