Research indicates that a substantial proportion of clients, maybe 30% or more, don’t show reliable improvements during therapy. So why is that? Why is it that therapy doesn’t always lead to change?
In my forthcoming book—Integrating counselling and psychotherapy: Directionality, synergy, and social justice (Sage, 2019)—I’ve developed a framework for understanding social and psychological change that, I hope, can help us to answer questions like this. The basic principle underlying the book is that human beings are fundamental directional: that is agentic, purposeful, acting in meaningful ways; and that we experience psychological difficulties when we can’t ‘actualise’ those directions that are most important to us in life, like self-worth, relatedness, or being in control of our own lives.
From this perspective, a first reason why therapy might not help is because there simply aren’t any ‘levers’ for therapeutic change. That is, the client is doing everything possible to actualise their most important directions, but the world just isn’t going to let them get there. For instance, a homeless young woman is depressed because she feels unsafe on the streets, marginalised, and drawn into drug dependency. She wants physical security, self-worth and some sense of purpose; and she is doing everything she can—within her context—to actualise this. Here, then, there may be nothing that therapy can help her reconfigure. Rather, what she needs is social, housing, or employment support to help her back onto her path; and probably wider social and political change.
From an existential perspective, the leverage that any of us have will, to a great extent, be limited. That is, there is a ‘cold’, ‘hard’ reality that is not just about the world we live in, but woven into the very fabric of human being. For instance, our longings for life, to achieve all the things we want, to have meaning, to stay connected to others, are all, ultimately, be doomed to fail. And yet, it may be in the very nature of human being to strive for these things. From this perspective, then, as philosophers like Schopenhauer have argued, we may be condemned to fail: to experience hopelessness, futility, and despair. Here, therapies don’t ‘work’ because people, ultimately, are going to fail in many areas of their lives: and no amount of talking about it or striving to reconfigure can ever save us from that existential reality.
Another possibility is that levers for change are possible, but that the client and therapist cannot—or do not—find them. A client, for instance, might have the potential to achieve greater relatedness by improving his communication skills, but the therapist focuses instead on trying to unearth childhood traumas, or on challenging dysfunctional beliefs. This is why assessment and formulation may be such an important part of the therapeutic process, and to be conducted in a relatively open, ‘non-schoolist’ way. Through this, therapist and client may be more able to see where the client’s problems lie and the points of therapeutic leverage, and then to either try to address them, or to refer the client on to someone who may be better able to do so.
It is also possible that the levers for positive change are there, but that the client’s directions away from them are just too great. Mostly, that means that the short-term emotional pain that they fear they will experience outweighs their directions towards longer term benefit. This may include the anxiety of facing the unknown and doing things differently, the burden of taking responsibility for one’s life, or the guilt of not having made changes sooner. As we know from the research, short-term directions—proximal, salient, and viscerally-felt—can have a much greater pull than long-term, inevitably amorphous, future possibilities. Short-term gains are like a powerful magnet, close by, that constantly pull people back into established ways of doing things: overpowering the effects of more distant, albeit ultimately more positive, attractors.
When assessing or working with clients, then, the question of whether there actually, are, levers to therapeutic change should always be kept in mind. Does therapy have the potential to help this person? And, if it does, what might draw a client away from ‘pulling’ those levers? As with ‘motivational interviewing’, acknowledging the power of the forces against change may be an important step in helping it to happen.