What makes people think that psychotherapy works?

Research does.

For instance, research has shown that psychotherapy works as well as medications alone for many cases such as depression. Most commonly, one finds the psychologist working together with the general practitioner or the psychiatrist to put together a regimen including both medication and psychotherapy.

The medication takes care of short-term symptom reduction, and the psychotherapy takes care of the factors related to the causes for those symptoms. In the end the best overall outcomes often require both, especially if a person is so debilitated by a psychological disorder that he or she cannot gain sufficient traction in therapy and is either a danger to him or herself or to someone else.

Often, when moderate functioning is present, people who don't like the idea of depending on "pills" prefer psychotherapy alone.

So, psychotherapy works, but there is a controversy among professionals as to the best way to conceptualize what makes it work.

Some folks adhere to what is called the "Evidence-Based Treatments" approach (EBT). According to this perspective one must have experimental research - usually involving random assignment of subjects, a treatment manual to follow, and two groups of subjects (one in which the procedure is used and tested and the "control group" in which the procedure is not utilized) - to validate the efficacy of any particular technique for any particular symptom or disorder, with regard to any particular group of people having that disorder.

One of the objections to this approach is that rarely does the actual clinician find a client who matches the pure laboratory conditions of subjects in the evidence-based research project. There is some evidence to believe that EBTs generalise to complex clients in real-world conditions, but the verdict is still out.

Many professionals feel that real people are just too messy. They usually come with a mix of symptoms, some of which fit this disorder or that disorder, but others come with symptoms that do not completely fit any particular disorder cleanly. Further, the complexities of one person's situation do not cleanly match those of another.

Many people, for instance, do not have just one disorder; they often have a layered assortment of psychological symptoms, psychosocial stressors, physical maladies, and more or less functionality. They come to a psychologist with a situation that involves a variety of other people as well as a variety of social contexts.

This leads to the second major way in which to view the psychotherapy outcomes literature. It is called the "Common Factors" approach. According to this perspective there are various features that are common to all approaches to psychotherapy and that make them all effective. Accordingly, cognitive-behavioral is just as good as brief psychodynamic, which is just as good as transactional analysis, which is just as good as gestalt therapy, and that is just as good as dream analysis.

What might such common features be? By far the most salient factor in positive outcomes is the client or patient him or herself. There is a variety of conditions, attitudes, needs, motivations, and particular specifics related to the complex situation that each client brings into therapy. This includes how the client makes use of the therapist and whether or not the client is committed to change enough to even come back.

The second most relevant factor is the relationship that develops between the therapist and the client. Some have also called this the "working alliance." What must take place is that the client must be able to connect with the therapist, and this usually depends upon whether or not the client believes the therapist is competent and whether or not the client feels accepted and comfortable enough in the presence of the therapist to speak openly and candidly about the very personal and sensitive matters comprising his or her life.

Many of these matters are very problematic; they are loaded with emotional provocation, and downright shaming to the client. It usually takes some measure of relationship building for a client to trust enough to endure such things in the presence of the therapist, and that is the substance of therapeutic relationships.

They are constantly being renegotiated during the course of therapy, and often the relational difficulties clients experience in "real life" can be impacted by working at the therapeutic relationship and coming to understand what a person does, and how they do that, in interrupting the contact between therapist and client. That is the "stuff" of therapy.

Psychotherapy works. It works because of some common factors present in good therapy wherever practiced by trained and experienced therapists. It also works because such therapists utilize tested techniques according to their best clinical judgments.

Both evidence-based treatments and common factors are the reasons that psychotherapy works. Consumers of psychotherapy services, then, are best served when they inquire into the ways in which therapists work and resolve questions about the expertise and competence of those offering such techniques.