Viewpoint - Good therapists are the key to successful therapy

Dr Ian Walton offers some insights into why some counselling programmes fail.

The counsellor is the key issue
The counsellor is the key issue

There is a huge amount of evidence to support the fact that counselling and psychological therapies work.1 According to Lebow 'psychotherapy is among the most tested and empirically validated health interventions'.2

On average, 80 per cent of those who undergo counselling or psychotherapy do significantly better than those who do not. Large amounts of money are being invested into psychological therapies by the Improving Access to Psychological Therapies (IAPT) programme, yet the programme appears to be struggling to achieve its anticipated outcomes.

Unintended fall-out from the programme includes mental health teams struggling in IAPT areas, as their members have left to join the IAPT programme attracted by the offer of a post-graduate training qualification. Perhaps we shall see more positive outcomes in the longer term as therapists complete their training.

NHS budgets are expected to shrink in real terms within the next few years. With new revised guidelines from NICE stating that patients should have explained to them the 'uncertainty' of the effectiveness of counselling and short-term psychodynamic psychotherapy for depression, unless we can demonstrate why counselling and psychological therapies should be available in every surgery, a great opportunity will be lost.

Quality of the therapist
A major reason why counselling and psychological therapies are in the doldrums is that NICE and IAPT are obsessed with using a proven methodology of counselling, generally cognitive behavioural therapy (CBT), rather than looking at what makes a successful counsellor or psychological therapist.

It is the skills and personal qualities of the counsellor or therapist that are by far the most important factors in the effectiveness of the therapy. Virtually all the research data demonstrate that all the various treatment approaches achieve roughly equivalent results.

This obsession with the treatment approach is highlighted by the fact that, since the mid-1960s, the number of therapy models has grown from 60 to more than 250.

Instead of being obsessed with the therapy model, we need to become obsessed with the effectiveness of the therapist. It appears that 87 per cent of the success of therapy is due to extratherapeutic or client factors, all linked to the quality of the relationship between the therapist and the client.

The ability to build rapport, access and use the client's own resources, using what the client brings to the consultation (in particular their theory of change), focusing on change and future orientation and obtaining valid feedback, is what really makes the difference.

Only 8 per cent of the remaining 13 per cent of change, that is just 1 per cent of the total, can be attributed to the therapeutic model or technique.

Why are we concentrating so much time, effort and resources on looking at the therapy, which in truth is not even a small slice of the cake, when we need to look at what makes the difference: the qualities and the flexibility of the therapist?3

NICE too has fallen into this trap, with statements such as 'CBT should be delivered only by suitably trained and supervised people who can demonstrate that they adhere closely to empirically grounded treatment protocols', which force us to focus on the therapy and not on the therapist.

Adapting your approach
Good therapists adapt their approach to the patient and accept their own limitations.

Bachelor showed the importance of the ability to do this. He showed that 44 per cent of clients specifically valued a cognitive type of empathic response and 30 per cent valued an affective-style response (the therapist indicates they share the same feeling as the client is expressing). About a quarter took empathy to be either a sharing of personal information via relevant self-disclosure or the offering of a particularly nurturing or supportive response.4

Even empathy means different things to different people. What is an effective style of empathic response for one patient may not be empathy at all for another.

Despite the view from the DoH that any trained doctor or therapist can do the job, when we are patients we actively seek out the doctor or therapist with whom we have built or can build a relationship and who 'understands' us.

We as clinicians tend to like patients who think and act as we do and struggle with those who do not. I know patients who will not move out of a GP's catchment area because they value this relationship so much.

The way forward is to focus on outcomes. There are now excellent outcome-focused tools that we can use to measure how effective a therapist is. They also allow the therapist to reflect after each session and discuss options with both the patient and their supervisor if the patient is not making progress.

There is a law of diminishing returns whereby the effectiveness of each session decreases as the therapy continues.5 Dr Scott Miller cites this as one reason why it takes only 18 months after a new psychologist starts for 85 per cent of his appointments to be filled by patients who are not progressing.

We need to be honest. We can not individually help everyone. If we are not helping, it is time to do something else.

Counselling and psychotherapy is divided by its different factions, each concentrating on their particular therapy, aiming to prove its superiority, when it is the therapist and not the label that is the important factor.

Focusing on measured outcomes is what will move counselling and psychotherapy on and help root out ineffective therapists, allowing the effective ones to continue to develop and hone their skills. Only with robust data will we silence the cynics and move an already proven form of treatment to the top of the mental health agenda.

  • Dr Walton is a GP and chair of Primary Mental Health and Education and chair and course organiser, Midlands branch of the British Society of Medical and Clinical Hypnosis
  • Declaration of interest: none declared


1. Lambert M J, Bergin A E. The effectiveness of psychotherapy. In: Bergin A E, Garfield S L (eds), Handbook of psychotherapy and behaviour change (4th edn) pp. 143-89. New York, Wiley, 1994.

2. Lebow J. New science for psychotherapy: Can we predict how therapy will progress? Family Therapy Networker 1997; 21(2): 85-91.

3. Wampold B. The Great Psychotherapy Debate: models, methods and findings. Mahwah NJ, Lawrence Erlbaum Associates, 2001.

4. Bachelor A. How clients perceive therapist empathy: a content analysis of 'received' empathy. Psychotherapy: Theory, Research and Practice 1988; 25: 227-40.

5. Duncan B, Miller S, Sparks J. The Heroic Client. San Francisco CA, Jossey-Bass Inc, 2004.

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