Researchers are always trying to figure out what is it about therapy that helps people change. In the old days, we used to think that the therapist was somehow responsible for any change in the way a client felt, thought, or acted. Clients would often lie on a couch or sit in a chair and talk, while the therapist listened, analyzed their problems, and prescribed solutions.
We don’t do that type of therapy anymore, though most people, especially our clients, think this is the way therapy “works.” Maybe it’s from watching Dr. Phil. Today, we believe that the client does most of the work in therapy. Therapists walk alongside the client, helping the client change what he or she wants to change.
When we study how well programs work, we usually focus on what we think is happening in therapy to see if our ideas are accurate. If we were to study meaning therapy in this way, we would single out what we thought was effective in the therapy and then check this out with the client.
The problem with this type of evaluation is that we may be blind to what is actually going on for clients. For instance, perhaps what really helped a client was that he gained hope for the future. If we just focus on whether he changed some behaviour or learned new coping skills, we may miss just how important his newfound hope is.
To avoid missing important information from clients, a growing number of researchers ask clients what they think they got from therapy and then see if these answers match what the researcher thinks. To let you in on a secret, it is well known from research that therapists and clients disagree at least 90% of the time on what was important in a therapy session. At Sunshine Coast Health Centre, we listen to clients because we believe that each client is the author of his life. Whatever way the client makes sense of his life will lead to the quality and type of life he lives.
Here are five things that we’ve learned from research on what people tell us is important in therapy. If you are in recovery (or know someone who is), some of these answers may be helpful to you.
Personality Change in Addiction Treatment
The idea that a change in personality could be used to see if therapy helped people is an old idea. Freud believed that only the therapist could decide this based on whether the person changed his or her personality characteristics.
Although the idea of personality change took a backseat in psychology, it has recently made a comeback. Today, some researchers give clients some tests that measure certain components of personality (not personality itself) to see if they have changed. A typical example would be coping styles. Perhaps a person who previously reacted impulsively has changed because he or she now thinks before acting.
A change in personality is a common idea in the treatment of addictions. Dr. Silkworth in the Big Book of Alcoholics Anonymous claimed that recovery demands “an entire psychic change”. William White calls it “transformational change” and William R. Miller calls it “quantum change”. Miller interprets this personality change as a change in values (what the individual believes is important to him or her). One of his studies showed that the values of people before and after recovery were different.
Whether our personalities change in adulthood or stay the same is a topic of great debate in psychology. Regardless of what you believe, the idea that we can change core things about ourselves in treatment is important. Our own alumni who are doing well in recovery often tell us that they are more open to new ideas, less impulsive, slower to anger, and rely more on their intuitions.
Behaviour Change Is More Than Just Abstinence
Typically, the public determines addiction treatment’s effectiveness on whether a person abstains from alcohol and drugs.
Yet, this is not a big priority for researchers. Researchers look at behavior change more broadly. They are still interested in discovering if clients abstain, but they are much more interested in learning whether clients reduce drug use after treatment, even if they don’t quit entirely. A typical survey asks for the number of days per month a client used before treatment and then after treatment. They are also interested in the amount and frequency of the drug use and whether the person has returned to his or her drug of choice or used some other drug.
Drug use is just one of many behavior changes the researchers are interested in. They are also interested in learning if the person’s physical health is better after treatment, if the person went to work everyday instead of calling in Monday morning with the “flu,” if emotional/mental health improved, and if family relationships were getting better.
For example, our alumni who are doing well in recovery usually tell us they:
- Have made new “sober” friends
- Started working out
- Have a safety plan in place when they go to places that serve alcohol (weddings, hockey games)
- Make sure they keep in touch with other alumni,
- Built up a good support network,
- Faced their fears such as speaking in public
Relationship Changes in Addiction Recovery
A more recent trend in determining if treatment helped is asking clients what they think is most responsible for their more positive mood, attitude, behavior, etc. The most important component always seems to be building trusting relationships with the therapist or other members of a group. It doesn’t seem to matter what the therapy does, this relationship building is consistently reported as the key.
This makes sense. One of the damaging consequences of addiction is that it isolates the individual. The typical pattern that occurs in addiction is to keep pushing people away. It’s easier to hang out with others who use than to keep relationships with those who don’t. Guilt and shame over his or her behavior usually makes a person feel less worthy to be around others as well.
Bruce Alexander said that “Addiction in the modern world can be best understood as a compulsive lifestyle that people adopt in desperation as a substitute when they are dislocated from the myriad intimate ties between people and groups—from the family to the spiritual community—that are essential for every person in every type of society”.
This highlights that we all need relationships.
Alumni who run into trouble usually tell us that they feel isolated and alone. Those who are thriving have usually formed trusting relationships with others.
Making Sense of Struggles in a New Way
A popular indicator of helpful therapy is a person’s ability to make sense of their personal struggle in a new way. Psychologists sometimes call this “cognitive restructuring”.
For example, a client might discover that addiction has a physical basis in the brain. That client might have thought that he was making a clear choice in using drugs, without realizing that the brain adapts to the drug, thereby making it much more difficult to abstain. With this new knowledge, he might feel less guilt and shame. Similarly, many of our new clients seem to think that they are at the mercy of their cravings — they won’t be able to deal with a severe craving. However, they learn that they can control cravings by using techniques they learned while in our drug rehab or alcohol treatment programs.
Our new clients generally have all sorts of ways of making sense of what went wrong in their lives and what they need to do to get over hurdles. Many of these ideas are not really based on reality and become a barrier to living a good life. For instance, a remarkable number of clients seem to believe that their recovery depends on their family. “If my family would just get off my back, I’d be okay” is a typical statement. Once they’re in treatment though and discover that they are the authors of their lives, they may start making sense of their struggles in a new way — one where they rely on themselves and not their family for recovery.
Some new clients also believe they have no choice over whether they use drugs. After learning about the famous Rat Park experiments (where rats avoided morphine if they were free to be themselves), these clients appreciated that recovery demands they be true to themselves.
Our alumni confirm what researchers have found. Those who are doing well actively change how they make sense of things in their lives. They tell us they listen rather than jump to conclusions, they reflect on alternative ways of understanding a person, and so on.
Finding Meaning in Life After Addiction
We pay a lot of attention to how clients discover or create a meaningful life. Even though clients said that a helpful part of treatment was learning to make sense of their struggles in a new way (“cognitive restructuring”), finding meaning in life is not the same. It’s much deeper. It’s not so much about making sense of this situation or that situation. Rather, it is about making sense of the big picture view of life.
The big picture depends on how we make sense of our lives. How a person makes sense of life (“the big picture”) will be reflected in the little things he or she does. If a person believes that the world is a dangerous place, then they will carry this idea everywhere in life. If a person doesn’t think much of him- or herself, then this will color how he or she interprets situations and people in life.
But what if the big picture was more positive? One participant in therapy put it this way: “Therapy helps because you see yourself and your situation in a new way. It helps you to see your history a little bit from above, or from the outside, or from a different angle.”
This comment is typical of those we ask about how therapy has helped them. They gain perspective on their lives. Narcotics Anonymous says that addicts are famous for making mountains out of molehills. Therapy seems to help them keep the molehills as molehills.