The subject of psychotherapy efficiency in healing has been a growing topic during for the last few decades and has been the subject of many empirical researches. Statistical techniques have been used to show its efficacy.( Miller, S.D., Hubble, M.A., & Duncan, B.L., P.23-24). This idea is still under extensive research and evaluation. While some researchers are looking into the effectiveness of psychotherapy, others are looking into the stability of this kind of treatment.(P.27) However, certain groups of clients are more vulnerable to relapse. Evidence shows that changes would stay be more enduring if clients attribute their changes to their own efforts (Lambert, M.J., & Bergin, A. E., P. 143-189) According to those evidences, if we assume the efficacy of psychotherapy and its stability, then we have to answer several questions such as, what elements are involved in psychotherapy? Which element should we be chosen as an effective one and what method delivers a better outcome? What method should be selected and what would be the limitations of the selected method?
This paper will discuss the reliability and effectiveness of psychotherapy methods for the healing process. It also addresses the above questions from the theoretical, clinical and empirical perspectives and borrows some evidence to clarify the answers. Finally, I will draw the conclusion, considering some limitations which might exist on the suggested method.
Many empirical and mathematical models have been generated to demonstrate the
meta-analysis is one of the mathematical techniques that has been used to show these effects.( Miller, S.D., Hubble, M.A., & Duncan, B.L., P. 24) A list of meta- analytic reviews of psychotherapy is provided in table 1 (P. 25-26) that will support the idea of effectiveness of psychotherapy in different disorders.
Meta-Analytic Reviews of outcome in Anxiety Disorders
Meta-Analytic Reviews of outcome in Anxiety Disorders
Meta-Analytic Reviews of outcome in Anxiety Disorders
In examining the common factors in psychotherapy, as an effective method of healing.(P. 25-26) it is possible to classify the therapeutic factors as:
- Extra therapeutic events,
- Relationship factors,
- Expectancy and placebo effects
- Technique/ model factors.
Each of these factors have their own effect and partially contribute to the outcome of the therapy.(Lambert, M. J., P. 94-129)
(Figure 1 shows the percentage of influences of each of those factors.)
Fig.1: From the Handbook of Psychology Integration by M. J. Lambert, 1992, p. 97.
As we can see in this Figure, therapeutic relationship has a remarkable contribution (30%) in the process of psychotherapy and client change.(Gelso, C. J., & Carter, J. A., P. 155-243)( Greenberg, L. S., & Pinsof, W. M., )( Rogers, C. R .) The client and therapist characteristics and their personal qualities could play a major role in make a good relationship. The therapeutic relationship, and its quality, is critical in the process of healing, beside the fact that in a mutual relationship the co- operation between two parties is also essential. The skill level of the therapist in generating a relationship has been demonstrated in several studies. ( Miller, S.D., Hubble, M.A., & Duncan, B.L., P.34) . The relation between therapist empathy with patient and its effect on the outcome is reported in some investigations.(Miller, W. R., Taylor, C. A., & West, J. C. P.590-601).Other studies have also found that the successful therapists are more understanding, accepting, empathic, warm and supportive.(Lambert, M. J., & Ogles, B. M., p. 139-193). A Research on this subject confirms that the success rate of therapist with positive behaviors is higher than those with no such attitude. In this study positive behaviors have been explained as warm, understanding, and affirming, behavior while negative behaviors have been defined belittling and blaming, ignoring and negating, attacking and rejecting. The authors of this study suggested that warmth, affirmation, and a minimum of attack and blame should have been taken in theraputical relation by therapist.(Najavits, L. M., & Strupp, H. H., p. 114-123) In recent years the interest regarding the theraputical alliance as an important subject in therapist-client relationship has increased significantly. This subject was first described by Freud.(Freud, S. (1912), pp. 97-108 & Freud, S. (1913), pp. 121-144) Gaston introduced Allaiance components as: “the client’s effective relationship to the therapist, the client’s capacity to work purposefully in therapy, the therapist’s empathic understanding and involvement, and the client- therapist agreement on the goals and tasks of therapy.”(Gaston, L., PP.143-153). We can see, in all of those studies emphasis on alliances are common. In fact both therapist and clients have to respect and adopt those aspects as important factors that will shape their alliance and make their relationship strong in order to get a better outcome. Another study related to this subject, emphasizes, tasks, goals, and bonds as three important components of the therapeutic alliances.(Bordin, E. S. (1976), PP.252-260 & Bordin, E. S. (1989), paper) Tasks as the actual work of therapy, goals, as the aims of the therapy that both parties have agreed on, and bonds, as the positive interpersonal attachments between clients and therapists that in case of existence in a mutual relationship, could create trust, acceptance and confidence between both parties. The importance of the relationship in-group treatment psychotherapy has also been emphasized in some studies.(Glass, C., & Arnkoff, D. B., pp.427-440), Lambert also suggested that 30% of outcome is related to the relationship between therapist and client, (Lambert, M, J., pp. 94-129) while in a meta- analytic study Martin, Garske and Davis (2000) found the effect of this factor only 5%. (Martin, D. J., Garske, J. P., & Davis, M. K., pp. 438-450)However, there is no evidence against the importance of this relationship in psychotherapy.(Bachelor, A., & Horvath, A., pp. 133-178, & Lambert, M. J., & Simon, w.)
The quality of relationship is another subject in therapy that has been considered in many studies as critical and important. Positive relationship can produce a successful outcome in therapy.(Gaston, L., Marmar, C. R., Thonpson, L. W., & Gallagher, D., pp. 104-112)A number of studies emphasize the role of early alliance to make a positive relationship. According to the result of those studies the therapist should be attentive in the first sessions of therapy and try to fix relational difficulties, if they occur during these first sessions, in order to make a stronger relationship with clients. .( Miller, S.D., Hubble, M.A., & Duncan, B.L., p. 139)
According to Alexandra Bachelor and Adam Horvath, the result of majority of research on this subject have shown that the therapists’ empathy and warmth, are two important factors that play an important role to make a positive relationship, however that therapist attitudes may be interpreted differently by different clients.(Bachelor, A., pp. 227-240) Interestingly, in most of the studies, we can see empathy as a common factor that clients with different types of views consider an important element in a positive theraputical relationship. In a study, which investigated the perception of clients, in regard to a positive therapy relationship, they found three different types of definition about elements, which can make a positive relationship. One half of those clients demonstrated a positive relationship while therapist offering specific attitude such as respect and being non judgmental, empathic understanding, and attentive listening. Forty percent of clients explained that positive relationship will occur while they (clients) could improve their self – understanding.And finally a small group of clients described a positive relationship in terms of co-operation between client and therapist. They proposed that collaboration between client and therapist is essential to establish and maintain a quality therapeutic relationship. .(Bachelor, A., pp. 323-337)
Another study on the effective factors in psychotherapy, indicates that clients’ involvement, such as their level of motivation that lead the client to collaborate during the therapy are very important parameters in therapy.(Orlinsky, D. E., Grawe, K., & Parks, B. K., pp. 270-376) For example, compare a patient who visits a family physician. The maximum collaboration from the patients’ would be visiting the physician and taking the prescribed drug on time and follow the doctors’ orders. The medicine will spontaneously affect the patient’s body. In contrast, in a psychotherapy relationship as many researches support, the clients’ involvement and collaboration in the therapeutic process play an important role, however some clients may not realize the effect of their positive and active involvement in a therapeutic process.(Bachelor, A., pp.323-337)
As we realized through these empirical evidences, theraputical relationship has an important role in the outcome of the client progress. However, by adopting some researches that have been done in positive effect of mindfulness in therapeutic relationship, we could see the role of it in enhancing the therapeutic relationship.
This is where mindfulness could play a significant role in the therapy process. Mindfulness can be integrated into therapeutic work in a variety of ways. Different areas of mindfulness, such as listening, empathy and presence can contribute to a therapeutic relationship. The research in these areas is in an early stage and there are not abundant documentation and results available on the subject, to draw a final conclusion regarding the positive effect of mindfulness in the outcome of a therapy.
Mindfulness “is the awareness that arises from paying attention on purpose, in the present moment, non- judgmentally, and to things as they are.” (Williams, M., Teasdale, J., Segal, Z., & Kabat-Zinn, J., pp.54) We can cultivate, sustain and integrate the way of paying attention into every thing that we do, including our relationships in general or therapeutic relationships in particular. As a therapist, we can cultivate, sustain and integrate the full attention with empathy, presence and deep listening by using mindfulness way into the therapeutic relationship. In fact using mindfulness allows us to shift from ‘Doing mode’ to ‘Being mode’, to live intentionally with full awareness and nonjudgmental in the present moment and turning off the autopilot mode. The ‘Being mode’ would help the therapist to be present at the moment and encounter with the client. Two types of mindfulness practice have been categorized as formal and informal mindfulness. Formal mindfulness refers to meditation practices and in contrast informal mindfulness refers to non-meditation based practices. Those methods provide the potential effect on therapeutic relationships. Many mindfulness researches have shown the effectiveness of mindfulness in clinical and theraputical aspects, specifically in chronic pain ( Kabat-Zinn, J., Lipworth, L., Burney, R., & Sellers, W., pp. 159-173 ; Kabat-Zinn, (1984), pp. 33-47, & Kabat-Zinn, (1990), stress (Shapiro, S. L., Schwartz, G. E., & Bonner, G., pp.581-599) depressive relapse (Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2002) & Teasdle, J. D., Segal, Z. V, Williams, J. M. G., Ridgeway, V. A., Soulsby, J., & Lau, M. A., (2000), pp. 615-623) disordered eating (Kristeller, J. L., & Hallett, B., pp.357-363), cancer (Monti, D. A., 2006) and also suicidal behavior ( Williams, J. M., Duggan, D. S., Crane, C. & Fennell, M. J. V., pp. 201-210; Linehan, M. M., Armstrong, H. D., Suarez, A., Allmon, D., & Heard, D. L., pp. 1060-1064) In one study by Wexler regarding the mindfulness in therapeutic relationship, he examined the quality of the therapeutic alliance and therapist mindfulness. He found the significant positive correlations between both therapist and client perception of the alliance and therapist mindfulness, in and out of therapy.(Wexler, J. (2006), phD Thesis)
In this paper, I will argue the effect of using three mindfulness components, empathy, presence and listening in outcome of a therapeutic relationship by using either formal or informal practices.
Many studies indicated empathy as a quality of compassionate understanding of another’s emotional experiences. It is considered as an important factor in therapeutic relationship and specifically in counseling literature. In Buddhist psychology, empathy and mindfulness are considered as vital components for awakening. (Germer, C. K., Siegel, R. D, & Fulton, P. R., pp. 81) Therapists could achieve this awareness and get an accurate understanding of their clients’ world through the mindfulness exercises. (Block-Lerner, J., Adair, C., Plumb, J. C., Rhatigan, D. L., & Orsillo, S. M., pp. 501-516), Rogers in his “client- centered therapy approach”, considered empathy as one of the several necessary conditions of psychotherapeutic change.( Rogers, C. R., pp. 827-832) Rollo May, also mentioned that empathy calls for “learning to relax, mentally, spiritually and physically, learning to let one’s self go into the other person with a willingness to be changed during the process”.(May, R., pp.97) Mindfulness – Based Cognitive Therapy (MBCT)(Segal, Z. V., Williams, J. M., & Teasdale, J. D., (2002)) and Mindfulness – Based Stress Reduction (MBSR),(Kabat-Zinn, J., (1990)) are two methods that would increase the individuals’ capacity for empathy by using both formal and informal mindfulness practices. Those practices will help us to bring our awareness to the present moment, accepting our thoughts, and ourselves without judgment instead of escaping from them or ignoring them. This procedure of awareness will lead us to a better and empathetic understanding of the emotional experiences of others. Acceptance and Commitment Therapy (Hayes, S. C., Strosahl, K. D., & Wilson, K. G.,(1999)) is also another mindfulness method, which helps people to be more positive and less evaluative or judgmental in their internal experiences.(Block-Lerner, J., Adair, C., Plumb, J.C., Rhatigan, D. L., & Orsillo, S. M., pp.510) Studies in this area indicate that if acceptance and non judgmental behavior increases in one’s own experiences it may help to increase acceptance of children’s experiences at a young age and as a result will help families to improve their positive and empathetic relationship with their kids.(p. 510) In “Zen Meditation or Zazen” study, (Maupin, E. W., 1962) the hypothesis was to determine the relationship between the practice of “Mindfulness Method” and the development of empathy in counseling student. This was confirmed by mindful sitting and breathing meditation.(Shapiro, D. H., & Walsh, R. N., pp. 42-57) In addition to the above researches, many other studies showing the use of meditation and mindfulness to cultivate empathy, (Lesh, T., pp. 39-74 ; Newman, J., pp. 1193; Pearl, J., & Carlozzi, A., pp.297-298; Reiman, J., p.1569; Riedesel, B., pp. 3274; Shapiro, S., Schwartz, G., & Bonner, G., pp. 581-599; Stile, J., Lerner, J., Rhatigan, L., Plumb, C., & Orsillo, S., poster session; Sweet, M., & Johnson, C., pp. 19-29)
However, review of those studies suggests additional research is required to achieve tangible results.
We can consider listening as a basic psychotherapeutic instrument. F. Fromm Reichman in response to the question that, what are the basic requirements as to the personality and the professional abilities of a psychotherapist, Stated that, “the answer is only one sentence, the psychotherapist must be able to listen”. Then he considered listening as an art that few people are able to practice without special training. (Fromm-Reichmann, F., pp. 7) Listening skills in many studies are considered as a vital component of any mutual relationship. However, in a clinical relationship due to patients’ mental conditions and presence of disorders, attention toward a meaningful and effective relationship seems more important. Penn (2001) “suggested that in dialogic approaches to therapy, listening is our primary form of care.”(Penn, P., pp.33-52) Such an emphasis on the importance of mindful listening is also central to Kabat-Zinn’s notion of dialogue as well as its being central in Nhat Hanh’s studies.( 1995) “Learning to listen and participate in conversations with others is the heart of healing care.” (Kabat-Zinn, J., p.449). “When we are mindful, touching deeply the present moment, we can see and listen deeply, and the fruits are always understanding, acceptance, love, and the desire to remove suffering and bring joy.” (Nhat Hanh, T., p.14) To listen mindfully means paying close attention to ourselves, and also to what others saying. It is about hearing the feelings behind the words that they are speaking, as well as being aware of the tone of our voice. We should say that this kind of listening is, in fact, a connection with our inner voice.
Listen deeply is one of the Insight Dialogue (ID) that will enable participants, to listen to each other deeply and process the information they received with minimum of bias. (Kramer, G., (1999) & (2006), pp. 4-8) Rebeca Shafir, a speech/ language pathologist and a neurotherapist, stated in her book, the listening as a part of the healing process. She argued that therapist could overcome the external distractions in their relationship with their patients by “conscious way of listening”. She claimed mindfulness listening as an “attitude” and not so much a technique. In her point of view, the therapist would be able to create and nurture and develop the trust, by using mindfulness listening.(Shafir, R., ch. 13, pp.2) Mindfulness listening is the main point in the establishing a healthy relationship. Mindfulness listening will also help therapists to be aware of patients’ needs and try to response attentively to them. Accept patients the way they are with no judgment. On the other hand, establishing this atmosphere allows clients to feel comfortable which will make them more open to the “possibility of change”.(p. 3) Rebeca indicated four characteristics for mindful listener based on her research. Those listeners are able to keep their attention for a long time, value the speaker and show their respect toward the speaker, they are able to see and hear the whole message. Mindful listeners are able to listen to themselves, which is the greatest challenge in becoming a mindful listener.(p. 7) Rebeca also stated that mindfulness practices, like meditation, will increase people’s ability to absorb the whole message and not only words which being said. When we listen mindfully, we will be able to recognize the body or emotional expressions, the tone of the voice and also the meaningful silence between the words. In fact, those practices make the listener’s body and brain ready to listen in any given situation.(p. 8) To show the importance of non- verbal communication, one study suggests that only “7% of the meaning of a vocalization is in the words that are spoken, 38% of the meaning is paralinguistic (the way that the words are said), and 55% of the meaning is in facial expression.” (Mehrabian, A., (1972))
In addition to empathy and listening, presence been described as another therapeutic gift that a therapist can offer a client. (Shepherd, I., Brown, E., & Graves, G., pp.70-77) The word ‘presence’ and its effect in psychotherapy outcome have been described in many studies.(Bugental, J. F. T., (1987); Hycner, R., (1993); Hycner, R., & Jacobs, L., (1985); May, R., pp. 37-91; Schneider, K. J., & May, R., (1995); Shepherd, I., et al., (1972); Webster, M., (1998), pp. 184-9). Rogers also viewed presence as a powerful healing component and an essential aspect of client – centered therapy. (Rogers, C. R. and Sanford, R. C., pp. 1482-501)
Maintaining a mindful and compassionate presence, also has been noticed by Buddhist psychologist to cultivate calmness.( Gehart, D., & McCollum, E., pp.220). As a matter of fact, the mindful presence means “to be open to whatever is brought into the room without disappointment or judgment.” (p.220) So, a mindful therapist would not be emotionally reactive to the changes that will happen during the treatment progress and not to be attached to specific outcomes. Dian Gehart stated in his writing that being mindfully present is important for marriage and family therapists, as well as in situation when that therapist is working with clients struggling with shameful or horrific conditions, for example childhood sexual abuse.(Gehart, D. pp. 5-14) In some studies, mindful presence is defined as a state of being, rather than a state of doing. It is considered as a vital component to nurture a therapeutic relationship. (Geller, S. M., & Greenberg, L. S., pp.71-86; McDonough, S. I., Kreitzer, M. J., & Bell, I. R., pp.S25-S41) Bien in their book, Mindful Therapy, looked at the mindfulness as the practice of being fully present and accepting the moment. He provides a unique focused activity to cultivate therapeutic presence and the ability to be fully present with clients.(Bien, T., pp.217)Geller and Greenberg’s (2002) have suggested meditation practices such as mindfulness, which is associated with Buddhism, in order to develop therapeutic presence in the state of being.(Geller, S. M., & Greenberg, L. S., pp. 71-86) However, we can also see similar spiritual beliefs in other religions like Centering Prayer in the Christian tradition.( Keating, T., (2006); Goleman, D., (1996)) have studied the meditative practices of different spiritual traditions.
Conclusion
In this paper, I have explored the effect and stability of psychotherapy in the healing process along with empirical and theoretical evidences. After reviewing studies in this area, I specified five therapeutically common factors. Eventually, I explored the role of theraputical relationship as one of those factors in three specific aspects, which can have a remarkable influence in the outcome of the therapy in three different area; listening, empathy and presence. I supported this notion by providing empirical and clinical evidence. Finally, in the last part of my paper according to some studies, I suggested the contribution of different areas of mindfulness in the therapeutic relationship, such as listening, empathy and presence.As I already discussed mindfulness is a way of living. It enables a person to be aware of her/ his feelings, thoughts, actions and emotions in her/his life from moment to moment. “It leads the mind back from theories, attitudes and abstraction to the situation of experience itself.”(Varela, F. J., Thompson, E., Rosch, E., pp. 833-839). According to Epstein, the goals of mindfulness are to encourage empathetic action in the world, understand the client, make correct decisions and alleviate suffering and pain, with due attention,( Epstein, R.M., pp.833-839) however to the importance of cultivating empathy, listening and mindful presence within both the client and therapist to improve the treatment outcome. Mindfulness training may have a great potential to improve the therapy process.
It is also suggested that while many studies in mindfulness have discussed the methods of improving the knowledge of the therapist in the field of mindfulness, additional research is required for examining the applicability of methods in involving the clients more mindfully in the theraputical relationship. Because of the mutuality of the theraputical relationship, the more knowledge and ability that the clients have the greater the outcome.
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