I’m not proud of how little I’ve posted here over the last several months. I’m hoping to be able to combine some energies from some different contexts and be able to put more up here. For example, this post is a Q&A from an MFT student about the similarities, differences, and overlap between Evidence Based versus Common Factors approaches. I also do some writing for some different services here and I could start placing them on the blog as well. I also love getting theory-based emails. And it makes sense to start uploading those here too, instead of writing back to one person at a time. Stay tuned. I hope there’s going to be an increase in production in this area.
Here’s the Q & A:
1. In your practice, do you tend to follow an Evidence-Based approach to selecting treatment options or a Common Factors approach?
I honestly hadn’t heard the term “Common Factors” in a long time so I had to google what that meant. Once I got the refresher, I still felt a little at a loss about how to answer. So #1 is going to really pull from #10 in order to make sense of an answer. I fully identify with gestalt. Here’s a run-down of the love story. In my last semester of undergrad, I had one professor for two psych classes. One of them was Family Systems and the other one, although I forget what the class was, had us read Viktor Frankl’s Man’s Search for Meaning. I learned I loved both of these things: Existential Psychology and Systems Theory. The same professor taught in the MFT program in Grad School so I followed him. He taught the very first course in the MFT program, Counseling Theory, during which he made the following comment: “Don’t ever say you’re eclectic. If you say you’re eclectic, it means you don’t actually know anything. Pick a theory (or two) and dive completely into it until you completely understand it.” Being like a baby bird with its mouth open ready to be fed, I took this to heart and started diving. I still get a little judgmental twinge whenever I hear a therapist say they’re “eclectic.” So I kept studying Systems Theory via the MFT program and my love for existential therapy grew as I started studying Irvin Yalom extracurricularly. (That same professor in that same course also said: “If you think you might want to practice from an existential perspective, you should be thoroughly on your way if you read “Existential Psychotherapy” by Irvin Yalom.” I’m pretty sure I ordered it as soon as I got home.)
So grad school progressed and I continued studying and loving existentialism and systems theory. Embarrassingly, I remember writing, “I don’t think there’s a lot of literature/research regarding the integration of these two theories,” and I wondered if that would be a niche for me in the field since they were my passions.
In an absolutely separate process, I had a different professor towards the end of grad school who said, “I’m Nick Hanna and I am gestalt. I follow the work of Irvin Yalom.” This was a little mind blowing for me since I hadn’t equated “gestalt” with “Yalom” before. Nonetheless, I was actually more struck with Dr. Hanna’s presence and I strongly wanted to possess whatever it was he had.
Several classes later, I had another professor and I thought, “hmm. It seems like you have some of whatever Dr. Hanna has. I don’t know what that is, but I want it.” Sure enough, about the halfway through the class, she said, “I’m gestalt.” “Ah ha!” I thought, “I’m on to something!”
A third class: a different professor: I’m thinking, “you haven’t mentioned it yet, but I can smell it on you. You have that thing, don’t you?” So I stayed after class one day and asked her if gestalt was an influence on her and she said, “absolutely, how did you know?” I said, “I have no idea.” She said, “I have the head of the Gestalt Institute of Pittsburgh on speed dial and it’s the time of the year for enrollment. Would you like me to give him your information?” Goodness yes. So I finished the MFT program and immediately attended the Gestalt Institute. The program was largely experiential, so I had to feed my theory-obsession extracurricularly. Turns out, gestalt is the integration of quite a few things, most notably systems theory and existential-phenomenology. Who knew? So all of my passions started channeling into a passion for gestalt.
So, to return to Question #1, gestalt doesn’t usually come to mind when people are naming “evidenced based” therapies. Personally, I don’t really have value for that term because I believe anything can be cooked up in a lab. And I think there’s a danger for therapists to be too “evidence” focused because then they’re thinking too much about the labs and not enough about people, nature, and life.
But I also wouldn’t have called myself “Common Factors” because that sounds more like “eclectic.” That said, I consider gestalt a *whole* theory and whenever I study things like Motivational Interviewing, DBT, REBT, Rogerian, Mindfulness-Based, EFT, and certainly CBT, I see them as clearly fitting with gestalt, just emphasizing certain *parts* of gestalt. Put everything together, form a whole, and you get gestalt.
So I suppose if I had to smoosh all these thoughts into one sentence and answer the question, it would be: “I am Common Factors because gestalt is integrative of all things and yet it hasn’t spent time in labs to make people see it as ‘Evidence Based.’”
2. Why have you chosen the approach you use? Why have you not chosen the alternative?
I do what I believe is best. It seems like “Common Factors” acknowledges there are truths that are pulled from a wide variety of camps. The danger of dogma is we may miss out on truths because they don’t have the right label as a source. It seems like “Common Factors” invites truths from whatever the source and ties them together. This aligns with where I am but, like I said, I wasn’t very sure of the term so I don’t know if I’m thinking about “Common Factors” correctly.
3. Have you spoken with colleagues about this topic? What option do they follow in their approach to choosing treatment options?
Yes. Some people are obsessed with evidence-based and I wouldn’t refer my close friends and family to them. I think there’s something to be said for focusing more on the torment in the soul and the fear of loss/change/death rather than focusing on what’s happening in a controlled environment somewhere else. I prefer therapists who focus on their clients.
4. What factors do you believe contribute the most to effective therapy in general? In other words, what actually contributes to changes a client (individual, couple or family) may make during the course of therapy (or soon thereafter)?
The first several things that come to mind are: empathy / understanding / acceptance / movement / choicefulness. I think that’s what we give to the clients so they can take it with them when they go. I think change happens from a spiraling exploration of those things, leaving clients with an increased sense of self (which could be synonymous with an increased sense of options or an increased sense creativity/efficacy). I appreciate the way the question is worded where the “client” can be the individual, the couple, or the family. I’m glad you’re in an MFT program. I think they do the best prepping as far as clinical skills.
5. Can you explain a little more about the significance of each of the factors you just mentioned?
I think we seek therapy when we have too strong of a sense of stuckness with too strong of a fear of change/loss. That’s a rock and a hard place.
6. Do the important factors change based on the needs of the clients? If yes, how so? If no, why not?
No, because the tension between homeostasis and novelty is universal and natural. Those two forces *are* the needs of the client. And there’s fear of death and a striving for preservation on both poles. Too much homeostasis is a loss of all and too much novelty is a loss of all. Therapy is helping the client enjoy the dance between those two forces and poles.
7. How important do you believe the therapeutic relationship/alliance is for your therapeutic outcome? What aspects of the therapeutic relationship are particularly important?
The therapeutic alliance is what differentiates us from self-help-books. It is of utmost importance. I think this is universal across all counseling theories but each theory would have a different answer for which aspects are important. This would be the “Battle for Structure” (Whitaker) and each theory emphasizes how to create the structure (relationship/context) they believe is most helpful. For me, it’s important they start to believe I am truly of service to their best interest. This often means there’s a directional change: at first they think I will tell them what’s best for them and then they learn they will tell me what’s best for them… and I will be listening closely.
The other huge reason the therapeutic alliance is important is the efficiency of the energy usage. If a client is using energy to defend against me, that’s wasted energy because I wasn’t the original problem that brought them to therapy. If there’s a true therapeutic alliance and they trust where I am coming from, then they (and we) can use *all* of the energy in order to tackle their psychological configurations and their original problem.
When I’m working with supervisees, I use the analogy of cleaners coming into your house, taking the milk out of the fridge, spilling it on the floor, and then using their time to clean it up. Even though there’s work happening and they’re cleaning, it produces a net effect of zero. A strong therapeutic alliance ensures our energy is used to tackle the things that matter… the things that brought them to the office in the first place.
8. To what extent do you believe hope and expectancy impact the outcome of therapy?
They need to have enough hope and expectancy to make it to the office and then we need to have enough hope and expectancy to energize the movement.
9. If you had to make an educated guess as to how important your theoretical model(s) or techniques are in determining the success of therapy, what would you say (scale from 0-100; 0= not important, 100 = the most important factor)?
Since it is 100% of what I am, 100% of what I do, and 100% and what they get, I’d give it 100. I have judgment for the word “technique.” It sounds too disconnected from the organic flow of energy and the depths of the I/Thou. “Technique” sounds more like “text-book” which sounds like “self-help book.” We can be better than that. Clients benefit when we are more than that.
10. What is your general theoretical orientation? How did you develop this approach?
11. What is one piece of advice that you can give me about developing my own counseling approach/theoretical orientation that may help me become the most effective counselor that I can be?
There’s a perfect reason each person is exactly the way they are. Don’t try and take that away from them. Explore them and learn them. This will help them learn themselves and will make them more able. Don’t *try* and change them. This is violence. Don’t be violent. Learn them. They will change in the process. At the center of gestalt is a concept called the “paradox of change.” When you connect fully with what exists as is, change happens naturally. This is the good type of change (learning/assimilation/integration/flow). If you’re aiming primarily at change rather than the whole, it will strengthen the force of homeostasis and then change will be more actively (naturally) resisted. Then the therapist will get frustrated with the client (even though the client is actually resisting in a beautiful, healthy, self-preserving way), the client will get frustrated with the therapist and themselves, and self-concepts will be split and damaged for them both. That’s not good for anyone. An understanding of the complementary yet polarized forces of homeostasis and novelty is crucial and it’s important that we see the whole of the client, not just violently pushing for the change of a part. This can be avoided very simply if you, as the therapist, genuinely have the intent of learning about the client. This, to me, is the respectfulness towards the client within the I/Thou approach coupled with the understanding and respect of the very powerful forces within nature (existentialism + systems). The change that happens when we have this respect and intent is very true and complete.
In short, don’t try and change the client so that you feel good about yourself. Learn how to explore *with* them. Then they will change and you *both* will feel good about yourselves. Therapy can be very fun and rewarding for both of you. A very strong clinician and I were joking around the other day and we agreed, “if you get ‘compassion fatigue,’ you’re doing it wrong.”