I am just starting to read the manual on Motivational Interviewing (MI). Among its application is in treatment of substance use disorder. As I read it, I become increasingly aware of how different this methodology is as compared to popular and contemporary skills-based approaches, such as Cognitive Behavioral Therapy (CBT). In fact, comparing the two, a CBT approach would instead approach therapy sessions in the opposite way.
With such confounding methodologies, what makes good therapy?
I’ve had my fair share of time being on the opposite side of the chair. Some were helpful, some were downright unhelpful, and some were… strange. All of these experiences were coming from qualified mental health professionals. So why the varied outcomes?
Being a practicing psychologist for some time now, here is what I’ve learned so far on what makes good therapy:
Reason 1: Effective and collaborative goal-setting.
Speaking from experience, alignment of treatment goals between therapist and client will result in high retention and engagement. Ideally, this process is collaborative, with regular assessment and re-visiting of goals. The client’s functioning can improve (or deteriorate) and priorities may change with time. Regularly auditing treatment goals can ensure that both therapist and client are on track in making best use of the client’s time and money. Oftentimes, clients are appreciative of the process. By doing this, clients can also make informed decisions with regards to continuing/ discontinuing treatment, or in managing the frequency of consultations.
Reason 2: Effective use of listening and/ or interviewing skills.
At the stage of independent practice, a therapist will require the application of basic counseling skills at an “unthinking” level of competence. It is the bread and butter of an effective therapist. This foundation of competence has to be first addressed before even applying fanciful methodologies. A lacking in this area and misapplication of skills would result in clients feeling unheard, hurt, rejected, or judged. In effect, it achieves the opposite of what a therapist would want their clients to feel.
Reason 3: Accurate conceptualization of the case.
A strange phenomenon I have observed is the hastened prescription of a “cause” to a client’s concerns. This is oftentimes without first having a comprehensive understanding of what is happening in the client’s internal and external world. At the least, a client has to first be understood from a biological, psychological, and social perspective. Only then can the therapist assess his or her competency in addressing any of the client’s concerns effectively, and to begin doing so. The target is oftentimes missed when the dart thrower is blindfolded.
Reason 4: Evidence-based.
Not only is there a wealth of literature regarding treatment methodologies, but of underlying psychological models and processes. These resources can aid the therapist in addressing a client’s concerns effectively. Till today, I am unpleasantly surprised at the extent of mis-prescription of a client’s concerns based on unfounded assumptions or downright wrong application of existing psychological knowledge. Such misinformation is harmful.
Granted, by the time a therapist graduates and begins his or her practice, he or she does not have the full extent of mental health knowledge. In fact, it is an area that is exponentially growing with time.
Educational institutions have to prioritize building competent fact-finding/ research skills with a strong foundation in ethical decision making. This is simply because it is not possible to teach all therapy skills in such a limited time. Similarly, a therapist would need to have a strong drive for continuous learning. Unless supervised, an ethical therapist also does not do a thing that he or she is not competent in doing.
Reason 5: Genuinely care.
There are variety of ways to show how one cares. Mental health professionals are trained to demonstrate this as a skill. As much as this can be trained, what cannot be changed is how a therapist genuinely feel about clients. One has to ask him or herself: “I want to show my clients that I care, but how much exactly do I really care?”
While sounding like a question first asked when embarking on this journey, it is instead one which has to be regularly answered. This is because it may change from time to time. Therapists go through the ebbs and flows of life. This can include changing financial, family, and career commitments. Also affecting this is the extent of how much his or her psychological and emotional needs are being effectively fulfilled.
In private practice, the therapist and client has to be engaged in at least a 50:50 transaction. That is, the therapist at least provides a service of equal value for the amount of ringgit that the client pays for. If the therapist is providing anything less than, clients can go out of the session feeling shortchanged, unfulfilled, slighted, or felt like a fallen victim to a clock watcher.
Principally, I believe that the value ratio should be instead 51:49, to which the therapist delivers 51% of the transaction. While a therapist can contribute more, the client’s contribution (in monetary terms) should not go beyond 50%.
Conclusion
Without even getting into the specific details of therapy or its many modalities, a therapist has to first overcome the momentous task of fulfilling the above. While simplistic in how these reasons look, it is in actual fact a challenge to effectively fulfill.
Undoubtedly, psychological therapy can be helpful. Given the right conditions, it can be a fulfilling experience to clients. Mental health concerns can be successfully addressed. As I continue reading the manual on MI, I keep in mind that a therapist has to always prioritize the first things first.