The Ingredients of Psychotherapy

On the Basic Ingredients of Psychotherapy

by Hans Strupp

There are 2 camps of psychotherapy, one is Rogers and Strupp who believe the non-specifics, especially the relationship factors and other factors that increased the consumability of the treatment and increased the hope of the client, are necessary and sufficient for change, whereas the other is composed of those like Garfield and Bergin who believe the non-specifics are common factors, but they account for little difference in therapy, and technique is truly what causes therapeutic change.

1) A basic ingredient of psychotherapy is a significant/helping relationship (much like the parent-child relationship and for Strupp this serves as a power base for effecting change)

2) This relationship provides the client with a place to untangle their previous parent-child relationship, revive the problems from that relationship, and to profit from this (Freud). It also creates a power base from which the therapist influences the client through common psychological techniques such as
b)encouragement of open communication
c)interpretation of unconscious material
e)reward manipulation

3) And last, a client who has the capacity for change

Psychoanalysis is designed to treat neurotics who are entangled still in bad parent-child relationships, and replay those problems from that relationship over and over. The therapeutic relationship mimics what a good parent-child relationship should be like. However, not all problems are transference problems, and since that's all psychoanalysis purports to treat, some problems are not best treated by psychoanalysis. However, the model presented above still deals with those problems psychoanalysis does not, and demonstrates the characteristics of other successful therapies. The common characteristics of all psychotherapies should be studied.

Basic Ingredients or Common Factors in Psychotherapy

Garfield responding to Strupp

Strupp gives his beliefs about the common ingredients to all psychotherapies, but it is incomplete. Garfield thinks that too often these factors are presented as necessary and sufficient, but this is not the case. While these factors, plus such factors as hope, trust, expectation of change, the social impact of the healer… all play a part, so does technique. Garfield likens psychotherapy to Spearman's general and specific factors, that the non-specific factors may be the general factors, and there are specific factors for each kind of therapy that account for additional variance, thus specific therapies would be better for specific problems. Garfield argues that Strupp's 2nd condition is not a specific factor; rather, condition 2 is probably a general factor, as insight is not a specific technique but a common technique of most therapies, and Strupp's list omits the new behavioral techniques. In closing, he points out that Strupp is right to include the client in the variance associated with therapy, but "good" and "bad" clients both change and fail to change, and perhaps the emphasis on clients results in pointing a finger at the "bad" clients and blaming them for failing to change.

The Interpersonal Relationship as a Vehicle for Therapeutic Learning
Strupp responding to Garfield

Strupp begins by noting Garfield's response is valuable. He notes that "general" and "specific" factors are largely differentiated by semantics, and the real distinction is "instrumental" and "non-instrumental." Techniques, isolated, would probably be most closely represented by behavior therapies: relationships, isolated, would probably be most closely represented by Rogerian therapy, although both attempt to straddle the fence at times. Although neither stands alone, the framework or therapeutic change, and the totality of the human seeking treatment require that the relationship is more important. As to the final comment of Garfield's, Strupp notes it is difficult to realize, but true, that there are some we can not help. Thus, we can realize this and settle for less, as well as develop more effective strategies.

Second Order Effects in Mental Health Treatment
Graziano and Fink, 1973

Clients usually go through a professional system before seeing their therapist, a system which may have negative effects. Thus while the therapist focuses on psychotherapeutic change, there may be other factors that undermine therapeutic change. Clients assume that they will be helped by therapy, or at least not harmed. where clients are harmed, other professionals may see it as the result of an incompetent professional.

Primary or first-order effects are goal specified, second-order effects occur outside therapy and are not "tracked" by the therapist or targeted areas of change. Often therapists take credit for these additional areas of change, but do not take credit for the possible additional areas of harm. First-order harmful effects would result directly from the therapist's behavior. Second-order negative effects could result from problems in the system, which could harm the client.

Since successful outcome is related to the number of sessions attended, the drop-out rate is important. In this study, drop-out was estimated at 86%, but other studies cited report 40% or more, and 60%. If only 14 client begin therapy, and only 10.5 clients get better (75%), just how good is therapy? While this may not apply, they comment, to educational programs, group therapy, inpatient therapy, or behavior programs, it is still an ethical responsibility to be aware of and attempt to correct where possible these negative second order effects if they harm clients.

Second order effects may compound this problem, such as high fees, social stigma, need for a baby-sitter, transportation problems, curtailing other expenditures of the family, financial and psychological debt, depletion of savings for retirement, emergencies, or college, altered work patterns & increased job stress, disruption of the client and the family's normal routine, loss of status and lowered self-esteem… all may interfere with therapy. Thus, it is possible that first-order effects only occur for a small % of the clients and second order effects effect most all, and dropout may not be due solely to "poor motivation." Luborsky et al found that a long waiting list was helpful to make the best use of an agency's limited resources.

Labels and sick roles may also play a part in this. The label applied to a client by the professional, the client, the client's family, and the courts may reinforce the "sick" or disabled and disordered picture the client has of him/herself, may increase discrimination against the client, may require the family to hide treatment, and may remove the client's sense of hope by implying a permanent illness.