Theo Tsaousides Ph.D.

Smashing the Brainblocks


The 3 Reasons Why Psychotherapy Fails

The factors that determine success or failure in psychotherapy

Posted Mar 21, 2016

Source: Speedkingz/Shutterstock

Psychotherapy has been around for more than a hundred years and has gradually become a standard of care in mental health. You would expect that anything that has been around for this long must be a very successful operation and that there is a lot to be learned from it.

But does it really work?

Despite the wide range of theories and techniques, the basic structure of psychotherapy has more or less remained unchanged over the years. The basic premise is the same. A client hires a professional to solve a problem. The kinds of problems that bring people to psychotherapy range from stress and anxiety about daily life to life-long challenges fitting in, relating to others, and reaching meaningful, personal goals. The solution to the problem is discovered, taught, and/or tested, through scheduled and structured discussions. To enable clients to solve the problem, therapists help them build confidence, develop insight, and learn new skills.

Since the 1950s, psychotherapy has been subjected to the ruthless objectivity of science. The results of the earlier studies were dismal. Psychotherapists seemed to be doing nothing more than keeping people company. In response to these disappointing findings, researchers and psychotherapists worked together to raise their standards, tighten their methods, and improve their interventions.

A lot of evidence has been accumulated since then that supports the claim that psychotherapy is effective. But the truth is that not all psychotherapy works, it doesn’t work all the time, and it doesn’t work for everyone. 

To better understand how success in psychotherapy can be achieved, look at the figure below. The three circles represent the three main components of psychotherapy: the therapist, the client, and the intervention. Psychotherapy is represented by the intersection of the three circles. In other words, for something to be called psychotherapy you need a therapist, you need a client, and you need an intervention. Client plus therapist without intervention means two people sitting in the same room. Client plus intervention without a therapist is what self-help is. And a therapist with an intervention but without a client present is probably in need of some training in marketing!

Theo Tsaousides, used with permission
Source: Theo Tsaousides, used with permission

Because all three components affect the outcome of psychotherapy, when psychotherapy fails to deliver on its promises it could be for one of three reasons: 

1.  The interventions are ineffective

Interventions are the techniques that therapists use in session to bring about results. There is a broad range of interventions, some of which are similar and some vastly different. In addition, some interventions are very specific, like eye movement desensitization and reprocessing, which involves following the therapist’s fingers with your eyes while thinking about a traumatic experience. Other interventions are more general, like life review therapy, which involves reconstructing your life story, including both positive and negative events. The bulk of psychotherapy research focuses on the intervention. Interventions are tested and if they work well for some of the clients on whom they are tested, they enter the hall of fame of evidence-based practices.  If not, they are refined, retested, or abandoned. While the intervention plays a significant role in the success or failure of psychotherapy, and it is the factor that has been studied the most, it is not the only one.

2.  The client is reduced to a diagnosis

For several reasons, psychotherapy research in the last 20 years has routinely focused on mainly one aspect of the client: the diagnosis. Using the diagnosis to choose the client makes research easier in terms of defining the problem, recruiting the right participants for the study, and drawing conclusions that are not overreaching.  However, two people with the same diagnosis are not the same people. What causes and sustains each person’s symptoms could be entirely different. For example, one person may be depressed after being laid off from work, while another person may be depressed because of a malfunctioning thyroid. The selected intervention may work for the first person but not for the second. Moreover, a person’s physical health, personality, expectations of therapy, readiness and commitment, living environment, occupational and financial status, social support and other life circumstances could have a much stronger influence on the outcome of psychotherapy than the diagnosis.  When psychotherapy research focuses on the diagnosis (and a few other easy-to-measure variables, like gender, age, and race), conclusions about success or failure are limited. When psychotherapy fails, it’s hard to know whether it failed because the intervention was ineffective, or because of multiple other client characteristics that had a significant effect on outcome.

3.  The role of the therapist is minimized

Just like not all clients are the same, neither are all therapists. In fact, therapists differ in many more ways than they are similar. Some of these differences have powerful effects on psychotherapy outcomes. While the more obvious demographic characteristics, like age and gender, don’t make a huge difference, other characteristics like their professional training and experience, their interpersonal skills, their emotional stability, their belief systems, and their personalities can affect the outcome a lot more. To keep the therapist variable constant in psychotherapy research, therapists are trained and supervised regularly. But even in such highly controlled conditions two therapists can come across very different. In the real world of psychotherapy practice, this homogeneity falls apart even more. Eventually, who the therapist is could have a much stronger effect on outcomes, than whether the therapist is using an effective intervention.

The conclusion? For psychotherapy to be successful the client, the therapist, and the intervention must fit well together. If any of these three factors is a mismatch with the others, therapy is bound to fail.

The same rule applies to other types of coaching and mentoring relationships.  Whether you are a provider or the recipient of services, you have to remember that success in this line of work requires the combination of a good teacher, a dedicated student, and an effective strategy that appeals to both teacher and student.   

The bigger question that remains unanswered is what successful psychotherapy really means. What does it mean to you?