Putting the psychotherapy spotlight back on the self‐reflecting actors who make it work

After decades of research, there is no general consensus on what the targets and outcomes of psychotherapy should be1. While this may seem a rather disappointing aftermath of much hard work, we should not despair. Psychotherapy research has come a long way and many effective therapies have been developed. The challenge now is to employ these therapies in such a way that the individual patients benefit from them optimally.

During the initial psychotherapy session, patient and therapist usually discuss the targets and outcomes of therapy and how they will go about achieving them. Subsequently, the patient is treated in accordance with the “treatment plan” . For instance, in the case of depression, loss of interest and low mood are often formulated as the targets of therapy. This is not surprising, given the enormous success of academic psychology and psychiatry in presenting mental suffering and its treatment within the “specialist” diagnosis/evidence‐based practice/symptom reduction/outcome monitoring model of mental health care2. As a result, treatments such as cognitive behaviour therapy are mostly oriented towards the specific target of symptom reduction.

Implicit in this approach is the assump‐tion that the psychotherapeutic setting is a static environment, in which the problems present themselves as symptoms, and that a specific solution exists to remediate these: the theoretical protocol. The elephant in the psychotherapy room, however, is that the psychotherapeutic environment is infinitely more dynamic. Patient perspectives are likely to evolve over the course of therapy, along with the impact, burden, meaning and acceptance of symptoms, and the theoretical protocol almost by definition cannot accommodate all this. It cannot be predicted how the patient perspectives and wishes will dynamically and non‐linearly evolve over time, but it seems unavoidable that they will. While the process of non‐linear change is inherent to the practice of real‐life psychotherapy, the theoretical framework underlying modern “evidence‐based” psychotherapeutic approaches does not explicitly address this.

Routine process monitoring (RPM) may be required in psychotherapy to oversee the patient's satisfaction and desired direction, on a session by session basis3, ideally combined with monitoring of contextual mental states in real life4. RPM includes measures of daily functioning, patient's satisfaction and patient's and therapist's confidence in the therapeutic alliance. It is based on a process of collaborative self‐reflection, and early results of the approach are promising5. Continuous patient feedback and collaborative self‐reflection can prevent dropout and allow, when required, a speedy recovery of the therapeutic alliance.

The therapeutic alliance is the foundation on which patient and therapist can evaluate the psychotherapeutic process. It is crucial to establish a safe environment wherein the patient feels comfortable enough to disclose his/her own input on where the therapy is headed and should be headed, as well as his/her feelings a‐bout the therapist's influence on, and input in, the psychotherapeutic process. Simultaneously, the therapist should express his/her own views regarding the patient and the psychotherapeutic process. This practice of collaborative self‐reflection is crucial in assisting the patient to reach his/her goals5. Indeed, evaluating the patient's dynamically evolving targets in each psychotherapeutic session has been shown effective in strengthening the therapeutic alliance and, in turn, in predicting self‐reported symptom reduction6.

The therapeutic alliance can be considered the basis of every mental health intervention. Extensive research shows that it is key in both psychotherapeutic and pharmacological approaches7. This is true for cognitive behavioural and interpersonal as well as for psychodynamic psychotherapies. Furthermore, the therapeutic alliance can interact with various elements of psychotherapeutic techniques, and this interaction can have a positive impact on outcome8.

Measures of therapeutic relationship correlate more strongly with outcomes than specific technical ingredients of psychotherapy9, and meta‐analytic research shows that different techniques are equivalent in effect size for most mental disorders2. Furthermore, the quality of the therapeutic alliance may be the most robust predictor of outcome. Psychotherapy research should therefore re‐evaluate its investment in technology and focus on developing ways to build stronger therapeutic alliances, and maintaining these over the course of therapy using RPM. While the body of research looking into alliance ruptures is steadily growing, there is little work on how to prevent such ruptures, which may effectively reduce patient dropout and facilitate the achievement of the desired outcomes.

There are now many psychotherapeutic interventions that for most disorders tend to show a similar efficacy at the group level. What we are currently faced with is the question of how the range of specific techniques can become effective agents of change, in the direction desired by the individual patients. A strong case can be made for an enhanced focus on the therapeutic alliance and on ways to use it to serve patient targets.

We will not know what the optimal targets and outcomes of psychotherapy are until we evaluate and re‐evaluate them together, patient and therapist, in a process of collaborative self‐reflection. By putting the lead actors back into the spotlight and empowering them with more focus and attention, we stand a good chance at achieving mutual goals.