If every form of therapy has roughly similar outcomes, what unifies them all?

(written by lawrence krubner, however indented passages are often quotes). You can contact lawrence at: lawrence@krubner.com, or follow me on Twitter.


Begrudgingly, I kept going back to what Alan Kazdin, a professor of psychology and child psychiatry at Yale University, said in 2009 in a widely cited paper: “It is remarkable that after decades of psychotherapy research we cannot provide an evidence-based explanation for how or why even our most well-studied interventions produce change.”

To complicate matters, numerous studies over the past few decades have reached what seems a counterintuitive conclusion: that all psychotherapies have roughly equal effects. This is known as the “dodo bird verdict” – named after a character in Alice in Wonderland (1865) who declares after a running contest: “Everybody has won and all must have prizes.” That no single form of therapy has proved superior to others might come as a surprise to readers, but it’s mightily familiar to researchers in the field. “There is so much data for this conclusion that if it were not so threatening to specific theories it would long ago have been accepted as one of psychology’s major findings,” writes Arthur Bohart, professor emeritus at California State University, Dominguez Hills, and author of several books on psychotherapy.

Even so, this alleged equivalence among various therapies is a product of statistics. It says nothing about what works best for each specific individual, nor does it imply that you can pick any therapy and obtain the same benefit. Perhaps some people fare well with the structure and direction of a cognitive approach, while others respond better to the open-ended exploration and sense-making offered by psychodynamic or existential perspectives. When aggregated, these individual differences can cancel out, making all therapies appear equally effective.

A lot of researchers, however, believe that this is not the only explanation. For them, the deeper reason why no single psychotherapy seems to provide unique advantages over any other is that they all work because of shared elements. Chief among these is the therapeutic relationship, connected to positive outcomes by a wealth of evidence.

The emotional bond and the collaboration between client and therapist – called the alliance – have emerged as a strong predictor of improvement, even in therapies that don’t emphasise relational factors.

Until recently, most studies of this alliance could show only that it correlates with better mental health in clients, but advances in research methods now find evidence for a causal link, suggesting that the therapy relationship might indeed be healing. Similarly, research into the traits of effective therapists has revealed that their greater experience with or a stricter adherence to a specific approach do not lead to improved outcomes whereas empathy, warmth, hopefulness and emotional expressiveness do.

All of this suggests a tantalising alternative to both the medical professional’s and the layperson’s view of therapy: that what happens between client and therapist goes beyond mere talking, and goes deeper than clinical treatment. The relationship is both greater and more primal, and it compares with the developmental strides that play out between mother and baby, and that help to turn a diapered mess into a normal, healthy person. I am referring to attachment.

To push the analogy further, what if, attachment theory asks, therapy gives you the chance to reach back and repair your earliest emotional bonds, correcting, as you do, the noxious mechanics of your mental afflictions?

…To Fonagy, a factor that is just as fundamental to the restoration of wellbeing in therapy is social learning. From the vantage point of evolution, we might be hardwired to mistrust others because a negative bias serves survival. Yet, for an intensely social species such as ours, being constantly on guard doesn’t bode well. How, then, do we trust, cooperate and connect with other people while also protecting ourselves from the threat that they might pose?

The theory of natural pedagogy, proposed in 2011 by Gergely Csibra and György Gergely, professors of cognitive science at the Central European University in Budapest, suggests an answer. In this view, evolution has engineered a nifty mechanism to relax our natural vigilance so that we can learn from others. To recognise relevant and trustworthy sources of information, we rely on certain visual and verbal cues or signals. In childhood, writes Fonagy in 2014, these cues are the same ones that underlie secure attachment (the special vocalisations of “motherese”, for example). Babies, in other words, are primed to trust the sensitive caregiver, who, in turn, teaches them how to trust others and navigate their social world. A study from Harvard University in 2009 shows that securely attached children are discerning judges of credibility – they trust mum when she is being reasonable but go with their own judgments when her statements run against reality. Their security in themselves and others turns these kids into adults open to new information, comfortable with uncertainty and flexible with changing their views in light of new data.