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Therapy

A Question Every Therapist Should Ask

It's not, "how does that make you feel?"

Key points

  • Research suggests that the therapeutic alliance accounts more for outcomes than modality.
  • Clients and therapists need to be on the same page in terms of their relationship and its purpose.
  • There is often incongruence between how clients and therapists believe therapy is going.
  • Frequent check-ins about how therapy is going is essential for effective treatment.

I perched aside my coveted graduate school desk. This had been my dream, the chance this program would grant me to learn the strategies necessary to help others. I imagined myself learning all about the therapies I admired. As it turned out, what I had the most gratitude for, however, was not a therapeutic modality at all, but a question.

It's a simple question that I routinely ask throughout sessions. I switch up the words, but the spirit is the same. "How is this (therapy, this session) going for you?"

Variations include, "What was that like for you, hearing my reaction?" "Please, correct me if I'm wrong." "How relevant does this exercise come across to you?"

It's not about seeking a grade. It's certainly not about reassurance. Therapy is a joint venture and it is essential to consult with your counterpart.

While the therapeutic modality is certainly important, research suggests that the effectiveness of therapy rests more on the therapeutic relationship than on which type of therapy is delivered (Wampold, 2015). In particular, the therapeutic alliance, and a shared consensus on the goals of therapy appear especially relevant.

In other words, clients and therapists need to be on the same team in terms of their relationship and on the same page about the purposes of the relationship.

A Shared Responsibility

While there is sometimes some intuitive understanding of how things are going between clients and therapists, there is often a discrepancy between how therapists and clients rate the therapeutic alliance (Marmarosh and Kivlighan, 2012). Similarly, there are often differences in expectations between therapists and clients for treatment (Benbenishty and Schul, 1987). The question of how therapy is going is necessary to address these topics.

While clients ought to be empowered to give feedback freely, the therapist must create an environment where feedback is welcome. One study found that 70 percent of respondents admitted to lying to their therapist (Blanchard and Farber, 2018), usually to spare the therapist's feelings. There is no need for this. Therapy is a space for healing. Feedback regarding how psychotherapy is going is just as important as feedback on the effectiveness of an antibiotic in a medical setting.

Protocol

In certain therapy modalities, such as Cognitive behavioral therapy, checking in on how therapy is going is a core part of the treatment's structure. In mentalization-based therapy, mentalizing the relationship, among other strategies, is incorporated to keep a pulse on the therapeutic relationship. Beyond this, requests for feedback can be integrated into almost any therapy.

Tools also exist that can be utilized across therapeutic modalities, such as the Partners for Change's Session Rating Scale (SRS) and Outcome Rating Scale (ORS) (Campbell and Hemsley, 2009). In a study of 148 participants, those who utilized these instruments in therapy saw greater changes in fewer sessions than those who did not (Reece et al., 2009). These scales give clients a way to provide feedback to the therapist non-verbally by simply drawing a line that indicates how they feel things are going between two extremes. The therapist can then measure and graph that line over time using the information gleaned to spark a conversation that may improve the process.

In Closing

If you are in therapy, know that your healing and experience of therapy matters. Hopefully, your therapist is asking you for feedback from time to time. If not, you may consider bringing up the topic. You can ask your therapist how they feel therapy is progressing and add your perspective for comparison. Checking in on therapy goals periodically keeps us on track. This feedback could make a real difference to the quality of your therapy.

To find a therapist near you, visit the Psychology Today Therapy Directory.

References

Benbenishty, R., & Schul, Y. (1987). Client—therapist congruence of expectations over the course of therapy. British Journal of Clinical Psychology, 26(1), 17-24.

Blanchard, M., & Farber, B. A. (2018). Lying in psychotherapy: Why and what clients don't tell their therapist about therapy and their relationship. In: Disclosure and Concealment in Psychotherapy (pp. 90–112). Routledge.

Campbell, A., & Hemsley, S. (2009). Outcome Rating Scale and Session Rating Scale in psychological practice: Clinical utility of ultra‐brief measures. Clinical Psychologist, 13(1), 1-9.

Marmarosh, C. L., & Kivlighan Jr, D. M. (2012). Relationships among client and counselor agreement about the working alliance, session evaluations, and change in client symptoms using response surface analysis. Journal of Counseling Psychology, 59(3), 352.

Reese, R. J., Norsworthy, L. A., & Rowlands, S. R. (2009). Does a continuous feedback system improve psychotherapy outcome?. Psychotherapy: Theory, research, practice, training, 46(4), 418.

Wampold, B. E. (2015). How important are the common factors in psychotherapy? An update. World psychiatry, 14(3), 270-277.

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