An argument has been raging for more than a century. It has taken on different forms and has had different combatants, but the issue is still the same:
What form of psychotherapy works best?
The question is generally broached in terms of psychotherapy as applied to the use of psychology-based therapies for individuals. (A very separate but similar battle exists in models of family therapy.) This is not a trivial issue. There are close to 200 identifiable psychotherapeutic models out there, of which perhaps 20 or so could be considered mainstream. These may be based on different philosophies or theories as to how change occurs. It seems quite reasonable to think that one should be right, or at least best, while the others are wrong, or at least less than the best.
The problem is that testing hasn’t really demonstrated this to be true. There have been attempts to create objective tests to see the rates of positive outcomes of different therapeutic models. In these research activities, the goal is to test the model itself, so the role therapist is sought to be eliminated as a variable. This has proven to be a problem. It seems as if the difference between therapists is greater than the difference between models. Suppose two therapists “1A” and “1B” utilize therapy method #1, and two therapists “2C” and “2D” utilize therapy method #2. Even if one could determine that that method #1 is theoretically more effective than #2, there is no real certainty that therapists 1A and 1B are more effective than 2C and 2D. The effectiveness of the two methods have such a range that there is huge overlap in the success rates of the two methods. The competence of the individual is a more important factor than the actual method used. This, however, is not to say that models are useless. Some models may be inherently flawed and should be avoided. Additionally, a mediocre model may be a more effective model in therapy than simply “winging it” because it provides structure and goals in the therapeutic process.
Val Wosket speaks of this in her book “The Therapeutic Use of Self: Counselling Practice, Research and Supervision. ” Miller, Duncan, and Hubble in 1997 (in “Escape from Babel: Toward a Unifying Language for Psychotherapeutic Practice.”) notes that there seems to be four main factors that guide whether one improves or not in therapy:
- Extratherapeutic factors associated with the client or the client’s environment.
- The relationship between the client and therapist
- The therapeutic techniques used
- The emotional state of the client (hope, expectation, placebo effect, etc.)
Looking at this, the therapeutic techniques used (or models) constitutes only one of the four. Two of the four the therapist does not have any control over. If one could eliminate the factors that the therapist has no control over, one is left with the techniques used and the relationship between the client and therapist. And within this, it seems as (if one is using a recognized therapeutic model at least) the relationship is more important than the specific model.
An added problem is that a particular therapy may work better for one type of problem than another. And even for the same type of problem, it is quite possible that different therapies may work best for different personalities of client. It is also further possible that different therapists may match up particularly well with certain models. Therapist A may work better with therapy #1 while Therapist C may work better with therapy #2. One size may not fit all in terms of problem, client, or therapist.
This is not to say that therapy models do not matter. But one finding is the importance of the counselor and the counselor’s use of self in the therapeutic process.
After reviewing many different studies, Wosket states:
“I strongly suspect that maybe it is not so much that all psychotherapies are equivalent. Instead (and this is a crucial difference) it may be that the most consistently effective therapists are in many respects equivalent and that equivalence derives more from factors such as clinical wisdom and the enlightened use of self, than from the utilization of techniques and systematic treatment procedures. …
Perhaps as well as considering ‘what approach is most effective and what can we learn from it?’ it might have been profitable for more researchers in the last few decades to have asked ‘which therapists are more effective and what can we learn from them?’ -p. 19
In the same book, Wosket quotes from Luborsky, McClellan, Woody, O’Brien, and Aurbach (in the 1985 article “Therapist Success and its Determinants”),
“…that the effectiveness of a given therapy can vary considerably depending on the group of therapists providing the treatment. This in turn suggests that the therapist is not simply the transmitter of a standard therapeutic agent. Rather, the therapist is an important, independent agent of change with the ability to magnify or reduce the effects of a therapy.”
So how does this apply to Pastoral Counseling?
Here are a few suggestions:
- Training of Pastoral Counselors should focus less on techniques than on developing the (counselor’s) self, and how to develope a healthy therapeutic relationship between the counselor and the client. Techniques do have some value, as well as models. But training that focus primarily on these may create a knowledgeable, yet spiritually, psychoemotionally, and socially impoverished, counselor. Training that takes seriously the therapy of the counselor needs to be taken seriously, even if it means a lessening of focus on classic competencies in therapy.
- Pastoral Counselors are in need of healthy supervision and peer support. As Lawrence LeShan stated (in “Beyond Technique: Psychotherapy for the 21st Century”) “A therapist who is not in supervision should be regarded either with suspicion or awe.” Pastoral Counselors are not automatons or therapeutic machines. They need these relational bonds and support for their effectiveness.
- Pastoral Counselors should not “fall in love” with one model or technique. No technique (or model) is likely to be the best for all situations. And even if a pastoral counselor becomes very comfortable and effective with one form of care, evangelistically promoting that technique to others may not be helpful to the others.
- Pastoral Counselors (should) draw more from their pastoral theology than from psychological techniques. Since pastoral theology is reflective and iterative (wrestling with the twin poles of theological tradition/perspective and personal experience), the counselor should always consider their models and techniques as tentative at best and part of a larger process of growth and change.
One final thing. In recent years there has been a growth of interest in empirical outcome-oriented research into chaplaincy (especially) and pastoral counseling (more generally). There certainly is value to this, since bad ideas can perpetuate in practical theologies such as is in pastoral care, when there is no analysis of results. That being said, the (still somewhat tentative) results in psychology should lead us to not be surprised if the same results will come to pastoral care— that the therapeutic self is more critical to care than a specific technique.